Process Integration

Success in heart failure demands process integration. As a chronic progressive disease, numerous clinical caregivers are required all along the continuum of care. Operational support is required within the hospital. A supportive infrastructure is required within the community. And a payment schema is required that rewards connectivity and integration – not necessarily individual performance ((optimization). These requirements are compounded by two other realities: 1). patients move back and forth along the continuum. Their care needs shift; 2). Heart failure is a disease with multiple co-morbidities. There is a higher level of complexity to ongoing patient management than most other medical conditions. The good news is that process integration can be achieved by design. The Colloquium’s approach using the Domains of Heart Failure incorporates process integration by design.

The continuum of care for heart failure represents a daunting level of complexity. While remaining mindful of the whole continuum, when considering process integration it is useful to parse the continuum into more workable subunits, the domains. Two substantial opportunities for integration become obvious: 1). within each individual domain: Community, Hospital, Clinician, Science; 2). the overlap between Domains, for example: Community and Hospital. Stepping back, a major largely untapped opportunity emerges as well: the integration of whole systems of hospitals caring for regions with multiple care communities within them. This approach is likely to represent a possible resolution to the current healthcare conundrum circa 2012-2015.

Each individual domain needs to incorporate all the resources needed to successfully carry out a care process within the domain except where it overlaps with other domains. This is especially true in heart failure where it is well established that nearly 100% of patients decompensate at some point and require inpatient hospital admission. So the first opportunities are to integrate within the hospital, the community, and among clinicians.

Using the Hospital Domain as an example, understanding the care process is essential to improving the process. Mapping the process is a basic method of gaining the insight needed. Relationship diagrams show the way to integrate (unify) across departmental boundaries. Most hospitals that do use these methods think in terms of how the patient “flows� through the process. This is a normal inclination and a good thing to do. However, it is limiting in itself. How the patient flows through a care process is important – but how the information about the patient (lab, imaging, etc.) flows through the care process is equally important. It is a rare hospital that uses value stream mapping to determine how information flows through the care process. The successful hospitals of the 21st century will be those that link the patient flow and information flow through clinical care processes.

Integration between the domains is the next opportunity. Interfaces (overlaps) are high opportunity zones. In nature, the interface between forest and meadow supports an abundance of life that can live in both environments. When something changes (lighting strike) the first opportunists are those who can take advantage of the new space, namely those who live in the interface. The woods take a long time to reclaim themselves and the grassland is ill prepared to compete. So too it is with healthcare today. With hospitals emerging as a predominant business model for care delivery, those hospitals and systems that can integrate the overlap first will be the big winners – and so will their patients. The Colloquium’s approach to the continuum of care enhances the opportunities to integrate across the boundaries: hospitals with communities, clinicians with hospitals, payors with systems, and on and on. The notion of occupying the interface between heart failure domains is an approach that will deliver excellent care across a broad constituency of people while maintaining good financial stewardship.