Don't Fear Clinical Integration: One Reason Community Hospitals May Have an Edge

There is certainly a push for clinical integration among healthcare organizations of all sizes and types today; and for good reason. Clinical integration has been shown to improve quality and patient service and reduce per capita costs all while coordinating care. Clinical integration extends the principles of the patient-centered medical home model of care beyond individual primary care practices to a system of care and is the foundation of accountable care organizations.

But clinical integration can be a daunting task for hospitals that have long relied on independent and fragmented medical staff. Smaller, community-based hospitals (as opposed to larger tertiary hospitals and academic medical centers) face further challenges in this pursuit. First, capital — in terms of both human capital and financial capital — is often harder to come by. Capital spending on equipment or other upgrades is often prioritized, making it less likely funds will flow down to integration efforts.

Many of these organizations also operate on smaller margins than larger health systems, so considering clinical integration on top of day-to-day operations adds another layer of strain on their resources. There is certainly less of a cushion between financial success and failure if any part of the integration efforts goes awry.

At the same time, their medical staffs are smaller, which means their physicians are already extremely busy and may have less time to devote to serving on new committees or otherwise being involved in integration efforts.

All of this said, many community hospitals have a leg up over their larger counterparts when it comes to one important factor of success for clinical integration: engaged physicians.

Mercy, based in Toledo, Ohio, includes seven hospitals that span a range of sizes. What strikes me about our smaller facilities is the engagement of their physicians. The percentage of medical staff who are active and involved in hospital operations and with administrators is higher than at smaller facilities. At Mercy, we are in the process of implementing an electronic health record system at our two smallest hospitals and the initial engagement of physicians as a percentage of the medical staff has been fabulous.

Why is this case? Well, for one, physicians who practice at smaller facilities, especially those located in more rural areas are physically at the hospital more because there often aren't hospitalists to care for their patients.

The smaller community hospital is an integral part of the community. It may be the largest employer, and the physicians, who live in the community, understand its integral connection to the economic and physical health of the people served. There's often a community spirit around the hospital, especially if it's the only one in town.

There are also stronger physician relationships across the medical staff. Primary care physicians and specialists are all sharing the same patients and run into each other more often, both at the hospital and outside its walls. The majority of the medical staff know each other professionally and often personally. As an organization moves toward clinical integration, the transformation starts with strong, positive relationships among physicians and administrations. If you already have that, it makes going forward a lot easier.

So how can community hospitals capitalize on this leg up? They must recognize that the future of healthcare delivery really requires physician leadership. Hospital leaders must truly engage their physicians in leadership, finding ways to encourage true leadership roles. At Mercy, we are trying to pair physicians with administrators, at every level, to make joint decisions that are the right decisions for transforming patient care and that support the future success of our physicians and the health system. Rapidly disappearing are the days of physicians being viewed primarily as referral sources to fill hospital beds. Rapidly appearing is a focus on developing physician leaders.

While engaging physicians in leadership may be easier in a smaller facility, it still needs to be a conscious decision on the part of hospital administration and its governance structure to allow physicians to lead in ways they have not led before. Their roles will need to expand beyond credentialing and other common medical staff issues. They must be engaged in answering the key question that will make or break your facility's reform efforts: How are we going to transition to future models of care and do it together successfully? The answer you arrive upon may involve tough decisions such as service line cuts or other resource reallocations. The best way to approach this process is to sit down and ask, "What is the goal?" Once that is agreed upon, work backwards. If the goal is clinical integration, employment is one way to get there, but it's not the only way. Depending on your hospital's resources, community and culture, a different approach may be a better fit.

The good news for smaller, community-based hospitals is the relationships needed for clinical integration are often present and strong. There may be a number of ways for smaller hospitals to sufficiently develop physician leaders and put in place the processes and infrastructure for clinical integration. Many smaller facilities already have or will pair up with larger systems. Luckily, this can occur in a variety of ways — affiliations, mergers or other partnerships — that best allow the hospital and medical staff to fulfill their mission while transitioning to new models of care under physician leadership.

Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio.  Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.

More Articles Featuring Dr. Kenneth Bertka:

Using HIT to Drive Clinical Integration, Patient and Physician Engagement and Population Health Management
Patient Engagement's Critical Role in Post-Reform Success: 6 Steps to Improve Patient Centeredness

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