7 steps for building a clinically integrated network

An increasing number of hospitals and health system leaders are setting their sights on establishing clinically integrated networks as they develop strategies to lower the cost of care and enhance value.

"Most of the country is still in a fee-for-service environment," Megan North, president of value-based care at Conifer Health Solutions, said during a presentation at the Becker's Hospital Review 7th Annual Meeting in Chicago. Ms. North was joined during the presentation by Gayle Capozzalo, executive vice president of strategy and system development at Yale-New Haven (Conn.) Health System. Conifer helped YNHHS structure its own CIN.

"The first step to really being able to drive a population health-based model is clinical integration," Ms. North added.

A CIN is a network of hospitals, physician organizations and non-acute providers across a market using established governance, measurements and defined incentives to create a virtually integrated delivery system that will enhance patient care and reduce cost.

A successful CIN not only improves access to quality care for consumers, but also improves clinicians' and physicians' access to insights into the health of populations. In addition, a CIN provides actionable data to better manage patients across the continuum of care.

However, there are several key considerations administrative and clinical leaders should ponder before embarking on the development of a CIN, such as the legal, clinical and financial elements impacting each party that may participate in the new entity.

Here are seven steps to developing a CIN, according to Ms. North.

Step 1: Gather interested stakeholders. The process starts by deciding if the network will be regional, statewide or only encompass a few counties, Ms. North explained. "When preparing to approach potential stakeholders, leverage admissions data to help identify your top referees and talk with them first," she said.

Numerous factors, such as market position and each entity's leadership, should be considered when evaluating potential partners. Other logistics-related factors, including geography, should also be considered.

"Really understanding what your partners are trying to accomplish is critical to reaching the outcomes you expect and moving forward together," said Ms. North.

Step 2: Create a value proposition. A strong value proposition forms the foundation upon which the CIN's governance is established. Once the participants are identified, every stakeholder will help define the network's value, and importantly, physicians must take a lead role.

"Discussions between primary care physicians, specialists and administrators were critical," said Ms. Capozzalo of the early stages of creating YNHHS's CIN.

While each participant has specific desires regarding value propositions, it is important to convene the stakeholders to ensure all parties involved are prepared to adhere to the same strategy. CIN participants cannot have competing interests — they must instead have aligned and coordinated incentives.

Step 3: Develop governance and participation agreements. One key element of this step is determining where the decision-making authority will reside as early as possible. However, each key stakeholder should have a voice in important matters.

It is also important to define board responsibilities upfront, such as budgets and capital investments; transactions on behalf of the entity; new membership acceptance or termination; and contract strategy and negotiation. According to Ms. Capozzalo, boards should include physicians and embrace their input in decision-making, as they are the ones actually implementing the clinical changes into their practices.

Ms. North recommends considering at least two layers of participation agreements, including local clinically integrated groups and independent physicians.

Step 4: Select quality measures. The next step is to create a framework to measure the entity's collective performance. Ms. North recommends establishing a quality measures committee and selecting five to 10 measures for every specialty. "You need to be able to communicate back to physicians on how they're doing," she said. "The goal is to get people to focus upfront on process-based measures and good citizenship measures."

Ultimately, CIN leaders must be prepared to bring physicians to the table and show them data on their performance. The quality measures committee should be versed in national standards and able to compare benchmarks to providers' claims-based data to assess performance. The key is to leverage technology to track quality outcomes and identify opportunities to improve patient care, according to Ms. North.

Step 5: Recruit physicians. The key elements of physician recruitment include identifying the types of providers the network needs; reviewing existing clinical performance metrics; making the case for why physicians should join the CIN; and isolating provider gaps and overlaps in the care networks.

Identifying and developing physician champions is paramount to physician recruitment, according to Ms. Capozzalo, because physicians automatically have more credibility with one another than administrators do. "It's important to spend a lot of time building a high level of trust among physicians on the steering committee so they can communicate the business case to joining the CIN to other physicians," she said.

Step 6: Measure and improve programs. All providers should be trained on quality measurement and reporting, but primary care physicians are central to managing patient care across specialties, according to Ms. North.

"When there is no coordinating point, the network is too fragmented," said Ms. North. She added that quarterly or annual performance report cards are not enough to drive improvement; instead, physicians in the CIN need tools that enable ongoing evaluation and education. Ms. North suggests leveraging technology to report their performances back to them in real time and linking performance to reimbursement. "This gets physicians' attention and keeps them engaged," she said.  

Step 7: Engage payers. The final step in the process is engaging payers in negotiations. Payers should only be integrated after legal standards have been agreed upon and the network has demonstrated it has a data-driven set of goals.

The network's value proposition to payers is the ease of working with a single organization that will provide all the care and services to their customers while lowering cost and improving quality.

In more practical terms, payers appreciate the administrative straightforwardness that accompanies working with an organization that both creates the infrastructure and provides the services. If a CIN can prove it can expand and attract more employers, payers will be interested.

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