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  1. Achieving Bidirectional IntegrationA Policy Summit Frank deGruy, MD, MSFM Chicago, IL June 22, 2011

  2. Executive Summary • From the Vantage of Primary Care • The Nature of the Fragmentation • The Range of Integrated Solutions • The Fundamental Policy Problem • How to Work Together • Clinical Integration • Vertical Integration

  3. Outline • From the Vantage of Primary Care • The Nature of the Fragmentation • The Range of Integrated Solutions • The Fundamental Policy Problem • How to Work Together • Clinical Integration • Vertical Integration

  4. From the Vantage of Primary Care • Population served • Diversity of patients • By problems • By payer • Diversity of practice forms • Press of practice & competing demands • PCMH & team-based care • External collaborations

  5. Outline • From the Vantage of Primary Care • The Nature of the Fragmentation • The Range of Integrated Solutions • The Fundamental Policy Problem • How to Work Together • Clinical Integration • Vertical Integration

  6. The Nature of the Fragmentation • Diseases vs. people • Mind from body • Patients from clinicians • Clinicians from communities • Generalists from specialists • Patients and clinicians from purchasers from payers from policymakers

  7. Outline • From the Vantage of Primary Care • The Nature of the Fragmentation • The Range of Integrated Solutions • The Fundamental Policy Problem • How to Work Together • Clinical Integration • Vertical Integration

  8. The Range of Integrated Solutions • For PCPs with single or simple payer mixes • For “private” practices • Consultations and referrals according to matrix • Upgrade in-house resources • IPA-type solutions • Other • Fast success, fast failure

  9. The Natural History of a Guidelines Shop • Guidelines • Implementation • Sustainability

  10. Outline • From the Vantage of Primary Care • The Nature of the Fragmentation • The Range of Integrated Solutions • The Fundamental Policy Problem • How to Work Together • Clinical Integration • Vertical Integration

  11. The Fundamental Policy Problem • What do we pay for? • Office visits • Procedures • For only some problems • What should we pay for? • Health! • Health care • Collaboration, integration • Innovation

  12. All Roads to Sustainability RunThrough Payment Reform • Measure health, healthcare, and cost outcomes • Pay for good health—within limits • Pay for quality care • Pay patients for participating • Pay for partners to practice together • Stop paying for bad care • That is fragmented & redundant • Stop paying for too much care • Health Plans are architects: try new designs

  13. Outline • From the Vantage of Primary Care • The Nature of the Fragmentation • The Range of Integrated Solutions • The Fundamental Policy Problem • How to Work Together • Clinical Integration • Vertical Integration

  14. How To Work Together • Clinical integration • Professional culture & practice style • Communication • Team-based care • Operating principles adopted by ICSI • Independence of thought • Diversity of opinion • Decentralization of authority • Ability to aggregate & share learnings

  15. Outline • From the Vantage of Primary Care • The Nature of the Fragmentation • The Range of Integrated Solutions • The Fundamental Policy Problem • How to Work Together • Clinical Integration • Vertical Integration

  16. How To Work Together • Vertical integration • The role of the convener • Adaptive vs. technical problem • Solutions for complex problems & Theory U

  17. Convener As Catalyst • Loose connections • Mapping (linking) • Passion • Emotional intelligence • Trust in process • Inspiration • Tolerance of ambiguity • Hands off approach • Receding • Backing away as work advances Adapted from “The Starfish and the Spider”(Ori Brafman) And--pointing at the “pole star”

  18. Adaptive vs. Technical(R. Heifetz-”Leadership without easy answers”) Adaptive Challenge is complex Need to address & change deeply held beliefs & values Loss is an inherent part of process Can’t be achieved within present system—people must acquire new capabilities Technical Problem is well defined Answer can be found within present system—requires application of abilities already in it Implementation is clear

  19. To a realistic shared solution A new group wants to jump to solutions But a wise convener leads them through the U C. Otto Scharmer (2007); Theory U Thanks to Gary Oftedahl for the Theory U diagram

  20. Productive levels of distress in human systems Limit of tolerance Productive Range Tension of change Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

  21. Technical vs. Adaptive Work Adaptive Challenge Limit of tolerance Tension of change Productive Range Threshold of learning Technical challenge Time Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

  22. Keep in mindthe social geographyof your project!