Blog Post

Coordinating Care in the Medical Neighborhood


Few would dispute the benefits of increased coordination throughout the care continuum. But actually improving care coordination is difficult to accomplish. It requires changing organizational cultures, modifying patient and provider behaviors, and aligning care models with financial incentives.

In our continuing conversation with Emma Mandell Gray about the medical neighborhood, we look at what it means to be a coordinated health organization, some of the roadblocks that exist, and a few success stories from organizations that are embracing population health management through these models.

Patient-centered care requires ongoing communication and coordination among members of a care team. So what tools and processes does a medical neighborhood need in order to achieve that level of coordination?

These teams are responsible for coordinating all care and developing individualized patient care plans that help define a clear path for any healthcare services needed, as well as any follow-up to be completed. It starts with establishing a solid understanding of who’s participating in the medical neighborhood – primary care physicians, specialists, and nonclinical staff – and defining each their roles and responsibilities. This is vital when you’re attempting to fully manage the patient journey across the care continuum. Additionally, it’s important to identify the sites of care, as well as the community connections and resources.

As for the tools, an IT infrastructure is necessary to allow for the secure exchange of clinical and other information. Various IT solutions are also necessary to assist providers in decision making, prioritizing patients by risk, identifying care gaps, and determining necessary interventions and ongoing improvements.

And of course, for sustainability, the model must be appropriately aligned with the organization’s financial goals and compensation plans to incentivize providers to furnish more value-based care.

Increased care coordination is a priority for both PCPs and specialists, particularly in the area of referral management. The medical neighborhood is designed to help with that issue. So why haven’t more organizations begun transitioning to this model?

One of the biggest challenges is that widespread adoption of population health management strategies won’t be possible until financial models and incentives further evolve and become more aligned. We continue to see an increasing trend toward value-based payment models, but they still aren’t prevalent enough to fully support the transition to the medical neighborhood model.

Also, implementing a supportive IT infrastructure can be costly, and figuring out what tools you need is challenging as well. Organizations have to develop a plan and assess their needs before investing in new IT systems.

Lastly, there’s the issue of buy-in and support. Changing entrenched behaviors among providers and staff is hard. And those changes must be sustained to really be effective. Having strong provider champions and other leadership certainly helps, but there also must be front-line staff support within primary care and specialty care to ensure a successful model.

Have any organizations successfully transitioned to a medical neighborhood model?

The medical neighborhood is a fairly new concept, and it’s still taking shape. Patient-centered care models typically take at least 3 years before organizations realize any substantial return on investment. However, there are certainly organizations out there doing quite well within the medical neighborhood model.

The University of Kansas Physicians (UKP) in Kansas City, Kansas, was one of the first organizations to bring its specialty practices into the patient-centered medical home (PCMH) model, which they’d been operating in for a few years. By doing so, UKP has dramatically improved its referral management processes, reduced costs significantly, realized a substantial reduction in unnecessary ER utilization, and experienced an improvement in transitions of care. And as a by-product of that, they’ve seen an increase in their patient satisfaction scores, which can probably be attributed to a more coordinated delivery system.

Two other examples come to mind – Bon Secours Virginia Medical Group in Richmond, Virginia, and Union Health Center in New York, New York. Both of these organizations have implemented various concepts and components of the medical neighborhood, starting with the deployment of the PCMH model and expanding it to include specialty care. And they’re doing very well in terms of coordinating care – they’re focused on the transition between inpatient and outpatient settings; they’re using consistent infrastructure and tools across the system. As with UKP, Bon Secours and Union Health Center have seen improvements in quality, fewer frustrated providers, and higher patient satisfaction.

What do you expect will happen to organizations that resist shifting to a patient-centered care model?

This is becoming the foundation for care delivery for a number of government and commercial programs and contracts. Organizations that are unwilling to move toward these models could miss out in a variety of ways. They could lose market share, with patients becoming savvier and seeking higher-quality care at medical neighborhoods. They could also lose their own provider and staff resources, because frustrations will continue to mount if those organizations continue working in fragmented, siloed models while the rest of the provider community is working in a coordinated system. Lastly, there are numerous ramifications around potential lost opportunities to receive additional financial incentives for operating within the medical neighborhood model. All in all, there’s a lot of risk to inaction, from a financial, clinical, operational standpoint, not to mention patient and provider satisfaction levels.

Emma Mandell Gray is a Senior Manager with ECG and has written extensively about care model transformation – including the medical home and medical neighborhood models. Her recent article, “It Takes a Village: Integrating the Medical Neighborhood,” appears in AMGA’s Group Practice Journal, and you can read it here.