The Integrated Care Model

 Care Coordination 

Sutter Care at Home’s Center for Integrated Care in Sunnyvale, California.
Agency Description:
Sutter Care at Home (SCAH) is one of the largest not-for-profit home health care and hospice agencies in northern California. Founded in 1906, SCAH is committed to compassion and excellence in home care, hospice, home medical equipment, home infusion therapy, and respiratory care, serving more than 150,000 patients in 23 counties each year. As an affiliate of Sutter Health, SCAH is leading the transformation of home care to achieve the highest levels of quality, access, and affordability.
Population Impacted:
The Institute of Medicine's report, "Crossing the Quality Chasm: A New Health System for the 21st Century" called for reforms to promote the delivery of "patient-centered" care. The new Sutter Center for Integrated Care answers this call by promoting care that is responsive to patient preferences, needs, and values, while ensuring patients' goals drive all care decisions. One of the center's initiatives is the dissemination of the Integrated Care Model (ICM) which is a person-centered, evidence-based, coordinated approach to care for all patients. The ICM program is designed to assist providers in achieving the "Triple Aim" of improving health, the experience of care, and the lowering of health care costs.

The Center offers an ICM course on the specific competencies needed to engage patients in their self-care, to assist with patient acquisition of self-management skills, and to build patient confidence with self-care. These competencies are relevant in the care of all patients, irrespective of their particular medical condition or problem. The course is structured in a “train the trainer” format to enable trained individuals to disseminate information gained from the course throughout their organization.
Strategic Partners:
To date, ICM model training has been provided to more than 4,500 health care professionals caring for patients in hospital and community settings in 47 states.

The center’s professional staff not only train health care professionals nationwide, but partner with providers to assist with “hardwiring” model concepts and ensure high quality care is consistently delivered over time. Hardwiring includes implementation of the best methods to identify patient barriers to self-care, embedding care plan interventions in daily care delivery, improving electronic medical record documentation to capture patient barriers, establishing patient-centered goals and tracking progress, and the selection of quality metrics to drive change and promote continuous improvement throughout the organization.
Three home health agencies are also embarking on a collaborative project to improve care transitions through the utilization of the ICM program, along with a transitions protocol. These agencies are receiving training with a focus on best practices in care transitions and will be implementing the ICM transitions protocol and evaluating protocol efficacy.
Project Description:
The ICM program was designed to improve the quality of care provided to patients with chronic conditions. At the time of model's inception, the healthcare system was transitioning from volume to value-based reimbursement. SCAH's prior experience with remote monitoring informed us that our patients were struggling with condition management. SCAH heard from clinicians during case conferences that many struggled to engage patients that seemed passive. With these needs in mind, SCAH conducted a thorough assessment of the literature to cull best practices from medicine and from social psychology and adult education. Seminal white papers and MedPAC data were central to model planning and refinement.

The ICM program continually evolves as new evidence presents itself and as we gather more information from patients about their care experiences. SCAH's guiding principle is that the patient must be at the center of health care team. One way SCAH puts this principle in practice is to include patients and caregivers in the development and evaluation of our patient-facing materials. For example, SCAH's new personal health record (PHR) is being field tested with patients and caregivers in clinical settings. Their feedback on all aspects of the PHR informs edits and design modifications and ensures that the end product is actionable and accessible from the user’s perspective—not just from a clinical perspective.
Project success is evidenced by patient, provider, and community endorsement. SCAH's new health literate "Stoplight" forms, designed to increase patient knowledge and inform actions for condition exacerbation, were recognized by the Center for Plain Language in Washington, D.C. with a 2013 ClearMark Award of Distinction. Patients using these forms—available for 13 different conditions—report feeling a greater sense of control over their conditions.

The ICM program was also selected as a 2013 Home Care & Hospice LINK Spirit of Innovation award winner for the model's focus on best practices and Sutter Care at Home's commitment to care. SCAH staff and hospital partners acknowledge the model’s value in making a difference in the care including promoting a sense of meaningful and valuable work.

Outcome Measures:
Suggested process metrics for agency adoption include:
  • Percent of staff attendance at weekly multidisciplinary case conferences
  • Percent of staff using Situation, Background, Assessment, and Recommendation (SBAR) communication in coordination notes
  • Percent of patients with patient-specific goal documented in EMR

Suggested outcome metrics for agency adoption include:
  • Acute care hospitalization rates
  • 30-day readmission rates
  • HHCAPS scores
  • Employee turnover rates
Results were tracked following initial model implementation at one agency over the course of two years. During this period, acute care hospitalization results were reduced from 29 percent to 14 percent, and RN nurse turnover was reduced from 20 percent to 6 percent. Agency patient satisfaction scores also increased, as did employee engagement.

A second evaluation is currently underway at Sutter Care at Home, related to the transitions protocol based on ICM tenets. At present, documentation of patient personal goals has increased from 10 percent to 80 percent, and 30-day hospital readmission rates for heart failure patients decreased from 25 percent to 10 percent over the course of one year.
Barriers to Implementation:
Barriers to ICM program hardwiring include constraints posed by an electronic medical record framework primarily designed to support Medicare regulations—not practice change. Prior to model deployment, work had to be completed to add a field for the patient’s personal goal and develop a method to run reports on the metric.

Another barrier is the realization for many providers that their behavior change is needed to promote a patient-centered approach. A collaborative approach where patients are presented with options and decisions are shared may run counter to current directive approaches. This approach must be supported with tools and opportunities to practice in order to facilitate this change. The institution of "TIP of the Month" sheets, which are short educational reviews, assist with provider behavior change. Other skills, such as motivational interviewing (a patient-centered communication style taught in the ICM class), take time to master. Key principles taught in class must be revisited continually until they become a normal and natural part of care delivery.