Background

Healthcare delivery innovation in the United States is focused on improving the “patient experience of care” as part of the triple aim proposed by the Institute for Health Care Improvement in 2007 [1]. These efforts can be attributed to the identification of patient-centered care (PCC) as a criterion of quality by the National Academies of sciences, engineering, and medicine (NASEM) [2] and the Affordable Care Act’s (ACA) support of innovations such as the patient centered medical home (PCMH) [3]. The NASEM’s definition of PCC includes “coordination and integration of care” recognizing the “special vulnerability that accompanies illness or injury” and concomitant dependence on providers to coordinate services and deliver timely information [2]. From the patient perspective, care coordination is integral to having their needs and preferences met, the failure of which is often perceived as “unreasonable levels of effort required on the part of themselves or their informal caregivers in order to meet care needs.” [4] therefore, despite care coordination (CC) and PCC often being seen as distinct healthcare delivery goals, PCC and/or CC (PCC/CC) are not mutually exclusive [5] and may be reasonably examined together.

Evidence-based PCC/CC interventions are a key tool for health system leadership seeking to improve PCC and CC, however the vast majority of PCC and CC efforts are explored through pilot, effectiveness, or mixed-methods studies at single institutions or within a single department. However, such studies are unable to provide evidence that adoption of the study intervention in a different health system would have similar outcomes [6].

Therefore, peer-reviewed studies exploring how various health systems facilitate PCC/CC at the institutional level may be particularly informative. The goals of the present study are to explore institutional-level facilitators of PCC/CC within multiple high-performing health systems and provide recommendations for health system leadership seeking to improve PCC/CC within their own institutions. Several recent studies examine institutional-level PCC/CC facilitators in US health systems through systematic review [7], single-case study [3], qualitative [8, 9], and mixed-methods [10] investigations. To date, peer-reviewed case series as well as realist reviews on this topic are limited. The present study adds a unique perspective to this body of work by comparing multiple cases, each individually analyzed using a realist review approach.

Methods

Study design and rationale

This study was conducted as part of a one-year project at a large, midwestern US health system seeking to improve PCC/CC. Sponsors for the project included executive leaders of the health system with expertise in health system management. These executive sponsors identified six US health systems with reputations for providing PCC/CC from which to identify best practices: Geisinger, Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Allina Health, and Saint Joseph Mercy (Trinity Health System). The health systems they selected are widely acknowledged as high performing health systems across many parameters in the US, with the lattermost health system having special relevance as a neighboring institution. These health systems represent a diversity of models found in the US; for example, fee-for-service versus salaried payment structures, or varied acceptance of the wide range of health insurance plans available in US versus management and exclusive acceptance of their own health insurance plans.

We used a holistic multiple case study design with a revelatory rationale; in this way institutional-level facilitators of successful PCC/CC interventions could be explored in-depth and then compared to reveal patterns of similarity, and ultimately, generate insights previously inaccessible in the literature [11, 12]. Each case was developed using a rapid realist review [13, 14] of peer-reviewed literature. Realist methodology is primarily concerned with “how complex programs work in particular contexts or settings” in order to “enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively.” [15] Unlike randomized control trials (RCTs) in which causality must be successive (i.e. if X, then Y), realist-informed causality is generative such that outcomes are the result of a special relationship – that of a specific mechanism or set of mechanisms working simultaneously within a specific context. Following this logic, realist review is well suited to delineating how the outcomes of PCC/CC inventions are influenced by mechanisms that necessarily operate within the context of their institution. In order to do this, the supporting literature for at least three successful PCC/CC interventions implemented per case institution were selected for analysis. Additionally, realist approaches may strengthen case studies or case series sensitivity to identify drivers of change in complex adaptive systems. Over the last 15 years, realist methodologies have been encouraged by the United Kingdom’s Medical Research Council to enhance health services research [6, 16]. In 2014, the formalized reporting guidelines for secondary realist evaluations was developed, from which this paper takes guidance [13] alongside elements of rapid realist review appropriate for the project from which this inquiry emerged, namely by focusing the research question and process to produce findings of practical relevance to a specific audience, rather than the development of a comprehensive theory [14].

Search strategy and selection criteria

Peer-reviewed literature supporting each case institution’s PCC/CC interventions was queried by one researcher in consultation with an information scientist in October of 2019 using the PubMed database. The following search was performed for each health system: “(Health System[Affiliation]) AND (“Patient-centered Care“ OR “Patient centered care” OR “Care coordination”).” If this yielded no results, a broader search by affiliation only was performed. One researcher screened peer-reviewed abstracts based on relevancy. Next, three researchers extracted information from articles deemed relevant from the screening into a matrix and assessed inclusion eligibility for the realist review sample. Two researchers at minimum read each article with one researcher reading every article and matrix entry to ensure consistency. Additionally, for each case, two researchers gathered gray literature queried via Google until saturation alongside detailed extraction of pertinent programs/initiatives on each health system’s institutional websites. Articles included in the review sample had to support successful interventions representative of each institution’s historical PCC/CC efforts, with literature rich enough for case analysis, i.e., detailed information about the intervention’s features, implementation, and institutional enviroment. An adapted PRISMA table with total and case-specific yields as well as inclusion criteria at each stage is depicted in Fig. 1. To be included in the final sample, an intervention had to have statistically significant or otherwise impressive findings demonstrating measurable positive impact on PCC/CC outcomes.

Fig. 1
figure 1

Adapted PRIMSA chart for peer-reviewed literature search and selection. PCC/CC = Patient-centered care and/or care coordination. *Broader search stream for affiliation only, due to zero hits when specified to PCC/CC. **54 additional articles regarding telehealth added from lists on institutional websites

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Data extraction and synthesis

Case profiles for each health system were compiled using both the gray and peer-reviewed literature, as well as any pertinent literature identified in the review articles themselves [14]. Intervention data from the literature were compiled by four researchers into open-ended templates [14] to explore mechanism-outcome relationships via the following sections: (1) Background: How did the intervention come into being? How was it designed? How was it implemented?; (2) Intervention Details: How does the intervention work? How do the “actors” interact with each other as a result of the intervention and/or its implementation?; and (3) Facilitators: What are explicitly or implicitly reported factors that helped with the success of the intervention? Intervention impacts and outcomes were also compiled, including impacts not part of the a priori framework of the study. One researcher with close familiarity with each article checked other researchers’ templates to ensure accuracy and consistency. The case profiles were then independently analyzed by four researchers, at least two per case, for institutional-level PCC/CC facilitators, and then compared in cross-case analysis. To do this, researchers paid special attention to how the health system facilitated the mechanism-outcome relationships. Researchers met to reach consensus on key findings through discussion, with one researcher participating in all meetings for consistency. Any discrepancies were resolved through discussion.

Results

First we describe our overall findings, then for each case we describe the institutional-level facilitators supporting their PCC/CC interventions, and lastly we describe the institutional-level facilitators identified in our cross-case analysis.

Our peer-review search yielded 20 articles related to 12 index interventions for 4 health systems: Geisinger, Kaiser, Cleveland Clinic and Mayo Clinic. Because Saint Joseph Mercy and Allina yielded research supporting less than three interventions, these cases were excluded. Table 1 provides key facts related to region, size, and population served for the included cases. Table 2 provides peer-review article information organized by case and intervention. The interventions reviewed represent a variety of strategies to improve PCC/CC related broadly to PCMH models, care transitions, provider communication, electronic health record (EHR) optimization, and teleservices. Interventions were implemented from the early 2000s to the late 2010s, with 83% having been implemented in the last 10 years. One intervention was not set up to report statistical significance [35] and another only reported limited statistically significant findings [26, 27]. They both otherwise report measurable positive effects that demonstrate potential of the intervention to improve PCC/CC. Table 3 provides the mechanism-outcome findings for each intervention identified through realist review. Figure 2 summarizes institutional-level facilitators by case, cross-case findings, and recommendations.

Table 1 Key health system facts for cases included in the final sample
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Table 2 Peer-reviewed articles included in realist review sample, by health system case and intervention
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Table 3 Mechanism-outcome realist review findings, by health system case and intervention
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Fig. 2
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Key findings and recommendations

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Institutional-level facilitators supporting Geisinger interventions

Elevation of care coordination work

As part of a strategic goal of innovation, Geisinger brought population health management directly into clinical care teams through the role of a case manager. This work was previously performed by external Geisinger Health Plan (GHP) offices [17, 18]. The case manager role became a critical to many of Geisinger’s PCC/CC interventions [17,18,19,20,21,22,23]. Clinical integration of population health management was supported through ensuring case managers had no competing care priorities [19] and creating information technology (IT) infrastructure for predictive risk modeling [17, 18], performance reports [17, 18], EHR-integrated longitudinal care planning [23], and provider alerts [20, 37].

Performance-based Incentivization

Goals of interventions were linked to performance categories like improvements in patient satisfaction and care quality [18, 37] that Geisinger providers were incentivized to strive towards; this incentivization accounted for up to 20% of total compensation per physician [37].

Institutional-level facilitators supporting Kaiser Permanente interventions

Learning health system practices

Learning health system practices supported the evolution of each intervention. For example, design for one intervention was directed by bottom-up assessment of patient need, and post-implementation performance was used to make improvements [24]. In another invention, 2000 hours of Plan-Do-Study-Act (PDSA) cycles were utilized to optimize intervention performance in the piloting stage [25]. Lastly, another intervention centering around a pharmacist call center arose after regular program auditing found long response times at nurse call centers frequently utilized for medication questions [26].

Organizing bodies dedicated to implementation

The interventions took place on a regional scale for maximal impact; this could not have been done without organizing bodies to support implementation efforts. Examples include “breaking down silos between settings and stakeholder groups” [24] and achieving buy-in and sustainability in 15 units across 14 medical centers despite initial unpopularity [25].

Open EHR

Kaiser’s EHR provided universal, standardized access across providers and settings essential to intervention features. In two interventions, pharmacists [24, 26, 27] had full access to patient records to enhance their medication reconciliation, while the success and design of a third intervention, a handoff protocol, depended on the EHR’s universality such that “an RN on any unit in any medical center could float or transfer to another unit or medical center and be proficient” [25].

Institutional-level facilitators supporting Cleveland Clinic interventions

Willingness to make structural change

Dramatic structural changes to accommodate patient needs guided two interventions [28, 31]. In both interventions, Cleveland Clinic multidisciplinary care teams were brought from Cleveland Clinic facilities to outside facilities to directly care for patients transitioning in and out of their institution’s care. Cleveland Clinic’s willingness to make these changes was considerable, demonstrated by working intensively with outside partners as well as significant resource investment. Similar willingness on the part of the organization to expend resources was observed through the incorporation of a mandated in-person, institution-wide relational skills course for physicians [29, 30], though no specific structural change accompanied this intervention.

Accountability practices

At Cleveland Clinic salary renewal is linked to performance, and extensive outcomes data is published annually, motivating provider commitment to improve the patient experience and/or outcomes [38]. The potential effect of this was particularly notable in one intervention, where Cleveland providers were held accountable to the success of the intervention through outcome-specific performance assessment [28]. Additionally, for a different intervention, researchers comment that success was in part due to their salary model, recognizing it would have otherwise been difficult to motivate staff participation [30].

Institutional-level facilitators supporting Mayo Clinic interventions

Culture of collaboration

Mayo’s explicit care philosophy prioritizes “union of force” wherein “personnel work collaboratively in teams within and across all departments to meet the […] needs of patients” [39]. Per the care philosophy, collaboration is reinforced by a salary model. The provider-provider collaboration one intervention formalized was directly related to these care goals, with researchers commenting that such collaboration is likely more effective under a salary model versus a fee-for-service model with no reimbursement for such collaboration [35].

Advanced IT infrastructure

Using technology to free up provider time [35, 36] and to connect providers across settings [32,33,34] was essential to the interventions, and appears to be supported by considerable investment in an EHR-integrated knowledge management system (described by Shellum, et al.) [40] and the supportive work of the Center for Connected Care established in 2015, which has helped implement at least 54 telemedicine initiatives [41].

Cross-case analysis

While each case presented unique institutional level-factors, there were factors in common which may be considered thematically as follows:

Institutional values for PCC/CC

Institutional values related to patient care explicitly or implicitly guided the design and mechanisms of nearly all interventions. Geisinger’s strategic goal of innovation, and Mayo’s care philosophy serve as particularly clearly stated and manifested value expressions.

Optimization of IT infrastructure to enhance performance and communication

IT infrastructure served to support care coordination work and its assessment; for Geisinger and Mayo in particular, a redesign of the IT infrastructure was the basis for increased efficiency and performance. However, the extent to which the technology achieved its goal was influenced by its effect on the quality of patient-provider or provider-provider communication. For example, in one of Geisinger’s interventions, automated patient calls were explicitly not intended to replace traditional patient contact; rather, they helped case managers know when to initiate a conversation [19].

Accountable reimbursement and incentivization structures

Key behaviors like physician collaboration and quality improvement activities were supported by reimbursement structures other than fee-for-service. This was an especially notable facilitator at Cleveland Clinic, where performance linked salary models served to motivate providers towards positive PCC/CC outcomes. Notably Geisinger and Kaiser both have integrated models – these not only support high-value behaviors at the provider level but also facilitate the ability to pilot PCC/CC interventions in the first place. Geisinger is uniquely positioned to leverage its health plan to develop the commercial market towards value-based care, since a third of its patients are both financially and clinically served by Geisinger entities [20].

Organizing bodies dedicated to implementation support

Cross-department or regional organizing bodies such as Mayo Clinic’s Center for Connected Care and various Kaiser departments were found to support intervention implementation. These organizations worked to break down silos between disparate clinical teams and fine-tune intervention improvement.

Discussion

This research illustrates how four highly successful health systems have facilitated patient-centered care and care coordination and can be used to inform initiatives in other health systems across the U.S. seeking to improve PCC/CC. Four key areas of focus resulted from our case analyses; in brief: (1) Institutional values for PCC/CC, (2) Optimization of IT infrastructure to enhance performance and communication, (3) Accountable reimbursement and incentivization structures, and (4) Organizing bodies dedicated to implementation support.

Based on these findings, health systems seeking to improve PCC/CC should consider taking the following steps. First, evaluate lines of communication between patients and providers and between providers, identifying and eliminating tension points and/or bottlenecks in communication infrastructure to ensure technology-as-used facilitates efficient and effective exchange of information, provider collaboration, and patient engagement. Second, evaluate the extent to which institutional prioritization of patient-centered care and care coordination is manifest and held accountable in performance feedback and values shared among departments and settings. This should be considered alongside how reimbursement structures may play a role in provider incentivization to meet care quality and patient experience goals. Finally, this evaluation work should be performed and/or supported by cross-department organizing bodies specifically dedicated to PCC/CC implementation work. Without such an organizing body, PCC/CC efforts may remain siloed within departments and/or clinical teams and may not be sustained, improved upon, and disseminated throughout the institution after initial pilots. Dedicated organizing bodies may be especially important because there is limited peer-reviewed research evaluating broad health system dynamics such as communication and institutional prioritization; such bodies might allow health systems to evaluate their own institutions on a continual basis, develop institution-specific best practices, and remain dynamic and responsive to change as institutional needs, patient expectations and technology evolve.

The available literature examining institutional-level PCC/CC facilitators in US health systems supports some of the findings and recommendations in the present study. For example, a 2013 primary qualitative case study of one health organization in Washington State found that to act upon on their major motivators of institutional-level change, moving away from an “unsustainable” fee-for-service model and continuously learning from past performance would be essential [3]. This is similar to one of the present study’s key institutional-level facilitators: using learning health system practices to optimize PCC/CC change within the context of an integrated payment model. Interestingly, the need for health systems to learn from themselves support the idea that even if there were robust institutional-level research on how to facilitate PCC/CC, health system leaders would still be required to look internally to identify what will bring about more PCC/CC in their own contexts and is suggestive of the need for organizational bodies to regularly support such work. Two other primary qualitative studies of reputable PCC health care organizations echoed reimbursement, leadership incentivization, and learning health systems as key PCC drivers [8, 9]. Despite general agreement regarding the importance of these factors, a 2015 study into highly ranked HCAHPS hospitals found that while nearly all of them employed some form of data feedback to drive improvement, only 57% offered incentives for high performance [10].

Interestingly, none of these previous studies commented on lines of communication and their relationship to technology and IT infrastructure, a theme highlighted in the present study, suggesting there may be benefits in using an approach informed by realist methodology. The case study is valuable because it offers a narrative of how various institutional practices interplay to affect PCC/CC change. In the case of this review, using realist informed methodologies to examine the mechanisms supporting 12 PCC/CC interventions produced unique findings related to communication. Further, this study used multiple cases to compare such narratives to arrive at more generalized best practices.

This study has limitations. First, the study is focused solely on US health systems which operate in a unique context that may not apply to health systems in other countries. Another limitation is the top-down case selection by executive sponsors. This limitation is somewhat mitigated by the expertise of the executive sponsors selecting the cases, who chose health systems with widely acknowledged reputations for PCC/CC efforts. Future researchers may rectify this by systematically identifying cases through using publicly available survey and rankings information for organizations of interest. Further, there was no outreach to leaders of the case study institutions to verify or qualify our findings. All findings were based on retrospective analysis of existing literature. Future studies may consider follow-up with researchers and/or health system stakeholders to verify findings, and/or conduct primary qualitative research.

Future research into large-scale and/or organizational-level change to encourage PCC/CC should consider case series with realist methodology as a potentially effective method to identify best practices. Given that many of the interventions identified in this case series may require significant financial and labor investment, a critical focus of future PCC/CC intervention research should include cost-effectiveness analyses to help health systems decide whether to pursue study outcomes. Related areas of research that should be explored include whether contractual inclusion of protected time for QI and/or research activities for health care professionals encourages PCC/CC on the institutional level, as well as investigations of challenges faced by institutions seeking to implement such PCC/CC-related interventions.

Conclusion

This study indicates that health systems seeking to promote PCC/CC should consider creation of institutional-level organizing bodies dedicated to such work. Key areas of focus for such bodies should include evaluating how IT infrastructure can be leveraged to improve communication, and the extent to which institutional prioritization of PCC/CC is manifest and held accountable in performance feedback, incentivization, and values shared among departments and settings.