Good Care Transitions Are Not Enough

We have to think about what’s best for this person, this patient, this resident, and carry that expertise throughout the different settings.

In today’s value-based care model, the focus is increasingly on incentivizing providers to do what’s truly best for the individual, the customer. Good outcomes are the goal, and the intent is to incentivize provider behavior that will produce such outcomes, at lower cost. That’s led to the realization that we need to have good hand-offs from one setting to another. In order to achieve coordinated, integrated care, information must immediately be transferred along with the individual. That means patient information including prescriptions, the treatment plan, the conditions they’re being treated for, and so forth, all must go along with the individual, from one setting to another. All of this is good – and important. But it’s not enough. 

Under the fee-for-service system, each of the silos within the continuum of care was incentivized to hold on to the individual using their services for as long as possible. Should that person have reentered a given care setting after being discharged or transferred elsewhere, it was all the better because payments would continue to be made as long as that person was in your bed. It was a perverse incentive, sometimes resulting in the hope that that patient would return, rather than heal and move on. It also placed different settings at odds, competing for dollars, rather than focusing them on working together to achieve good outcomes. As a result of these and other pressures, each setting functioned as a stand-alone silo and profit center. 

It’s time for those silos to break down and start working with each other. If that doesn’t happen, and coordinated care is just about good handoffs from one silo to another, we won’t actually benefit the customer, nor will we truly save money in terms of total healthcare spend. We will still be furthering that siloed mentality, in which experts in each silo still make decisions, independently of the experts in other silos, such as the hospital, skilled nursing, assisted living, or home health care settings. 

Each time you hand off to a new setting, the senior healthcare professional in that setting becomes like a dog marking its territory.

I can offer two illustrations of this problem. The first was related to me by a skilled nursing executive. Because the family members of a resident knew this executive, they called him to discuss their mom. She was on a managed care plan and had just been discharged to one of his properties from the hospital. Within 72 hours, they received three phone calls, from three different care coordinators: one from the health system, one from the managed care plan, and one from the skilled nursing facility. In each case, the call was to advise the family as to what was the best care plan for their mother. They clearly had not spoken to one another, let alone coordinated, as they each offered a different approach to her care. The family’s reaction was “no wonder health care is so expensive, and so screwed up.” All of the calls were made in the name of executing a good handoff. 

Another illustration I use comes from my time as a Maryland state representative. I sat on the committee which regulated all the different healthcare professions in the state and got to see all of their turf battles. Every group, from Podiatrists to Ophthalmologists, would come in and argue about who was qualified to do what. Each group would argue that only they were qualified. Today what I see, in terms of these different settings, even if there’s agreement on the need for integrated, coordinated care, reminds me that not much has really changed.  

If we just have a different team of experts in each setting, we’ll have turf battles – and the loser will be the individual receiving care. 

Each time you hand off to a new setting, the senior healthcare professional in that setting becomes like a dog marking its territory. They routinely overrule the other silo. You might hear a hospitalist say: “I don’t know why the consulting doctor in the skilled nursing facility recommended this prescription and that you do that therapy.” The skilled nursing physician might say: “I don’t know why they put you on that in the hospital; that’s nuts, given your history – they must not have looked at that.” Then the managed care company comes in, saying: “I don’t know why either one of them is doing this; that’s so expensive, and so uncalled for.” In each case, they’re saying, “we’re the experts” and they show it by stepping all over the advice the patient got from the other care settings. 

This dynamic is why, if all we focus on is good hand-offs, we will fail to truly produce the best outcomes for the patient, at the lowest possible cost. Instead, we have to have coordinated, integrated care not just in the hand-off, but across all the settings and throughout the individual’s care journey. We have to think about what’s best for this person, this patient, this resident, and carry that expertise throughout the different settings. If we just have a different team of experts in each setting, we’ll have turf battles – and the loser will be the individual receiving care.  

There are practical examples in which coordinated care teams disrupt old silos and achieve integrated care at lower cost. For an excellent read on the practical aspects of coordination, you can download the paper “How Disruptive Innovation Can Finally Revolutionize Healthcare”. Written by Clayton Christensen, Andrew Waldeck and Rebecca Fogg of Innosight and Christiansen Consulting, the paper, which is subtitled, “A plan for incumbents and startups to build a future of better health and lower costs” provides evidence that this approach is not only cost-effective, but necessary if we really wish to achieve great outcomes for Americans. We recommend anyone interested in achieving better outcomes, at lower cost, read the paper. I welcome further discussion and comment from those in the business of caring for people – across every setting – on how best to achieve meaningful results.