Collaboration across clinical silos.

WE FACE SIGNIFICANT challenges to healthcare integration-supply- driven demand; expensive new technologies (yet unlinked to better outcomes); physician-centric care; and a lack of leaders and clinicians with knowledge of epidemiology, quality improvement, finance, innovative models of care, and best practices. We likewise face tremendous opportunities in healthcare reform as we endeavor to provide a coordinated continuum of high-value services to defined populations for which we are clinically and fiscally accountable. To truly transform the US healthcare system, we must integrate our clinical care across the care continuum, managing individuals and populations across episodes of care and aligning funding through pay for value, per-episode bundled payment, or elements of capitation, such as accountable care organizations (ACOs) or global payments (Ginsburg 2012). We must prepare for this new environment through clinical alignment of inpatient and outpatient systems and providers, thereby creating seamless care.Most healthcare experts now agree that breaking down the clinical silos of complex healthcare organizations-known as integration-is beneficial. While some have led this effort, others have resisted. Evidence from highly integrated systems and early adopters indicates that integration improves value and access and increases patient loyalty. Sufficient evidence points to sound principles that can inform the clinical integration process (Suter et al. 2009).In this commentary I consider clinical integration practices that are use- ful in breaking down clinical silos, examine how those practices were employed at UnityPoint Health and Piedmont Heart, and offer personal anecdotes about building innovative care programs in a large, southwestern, academic, inte- grated health network.What principles can be widely applied? A healthcare system (whether taken as a whole, such as UnityPoint Health, or as one part of a whole, such as Piedmont Heart) is a collection of critical functions, including governance, planning, finance, service delivery, monitoring, and evalua- tion, that are influenced by the prevailing values, beliefs, norms, and regulations of multiple stakeholders. Integration of those functions requires understanding and analysis of complex interrelated and interdependent relationships, as well as alignment with regulatory mechanisms, accountability networks, reporting and management procedures, financial functions, technological requirements, and the fiduciary systems that monitor reimburse- ment processes-a seemingly overwhelming undertaking. Clinical integration is the extent to which patient care services are coordinated across functions, activities, and sites over time to maximize the value of services delivered to patients or covered populations (Shortell, Gillies, and Anderson 2000).Critical integration factors and specific recommendations for breaking down clinical silos are summarized in Exhibit 1 and discussed below as they relate to the two feature articles.TRIPLE-AIMED LEADERSHIP AND CULTUREReinvention requires exemplary-even courageous-leadership, significant cul- tural change, and active imagining of the future. It calls for working collaboratively across the silos that divide payers, health plans, hospitals, clinics, and providers to forge a common vision, a shared culture, and mutual accountability for patient outcomes. The underlying beliefs, values, norms, and behaviors of the system can either support or inhibit clinical integra- tion (Gillies et al. 2006). The difference between leading to integration and man- aging to change is a shared, triple-aimed vision for (1) improving the health of the population; (2) enhancing patients' expe- rience of care, including quality, access, and reliability; and (3) controlling the per capita cost of care.Both UnityPoint Health and Piedmont Heart had visions of developing, pursuing, and implementing triple-aimed strategies to achieve greater value. …