How Can Healthcare Be Better Integrated Across Boundaries?

Executive Summary

The concept of integration has become a focus of policy makers and healthcare organizations across the globe. There are countless definitions and the underlying concepts mean different things to different people in different contexts at different points in time. Integrated care was proposed in a recent report as "a term that reflects a concern to improve patient experience and achieve greater efficiency and value from health delivery systems....through better coordination of services provided."1 Reducing silos and fragmentation are purported to facilitate consistency and cooperation between different areas of the healthcare system to better meet the needs of patients. To make integrated care effective, a multidisciplinary focus with the active involvement of teams of participants is crucial. 'One-size fits all' solutions are unlikely to work well and may create further problems whereby patients can 'fall between the cracks.' The following strategies can be used to better integrate care across boundaries:

  1. Use technology as a means to communicate with other providers;
  2. Focus on specific populations to deliver care that is tailored to better meet patient needs; 
  3. Focus on transition points where integration is most likely to be at risk; 
  4. Empower patients and families to help design a more responsive system; and
  5. Incent providers and organizations to make integration a reality.

We are interested in generating some discussion on this topic in our Care Integration Community. Please visit this space to join the conversation.


Use Technology as a Means to Communicate with Other Providers

Eliminating silos so that providers can share information and resources is critical to smooth patient transitions across boundaries (e.g, hospital to home care). Telehealth will help in the provision of integrated care and will become a key component in the future of integrated care. Succesful case study examples of the use of e-health technology to improve communication between hospitals and other sectors (primary care, community care) include: 

Focus on Specific Populations to Deliver Care that is Tailored to Better Meet Patient Needs 

Integrated care is most necessary in scenarios where organizations are caring for patients who have complex needs. These patients often account for higher health costs as compared with healthy individuals. Many organizations are beginning to utilize bundled care approaches (including payment models) to develop and deliver care for specific high-needs populations (e.g., those with specific chronic conditions including mental health). More information on specific primary care - mental health integration efforts can be found here as well as a good discussion of macro level policy issues across four levels of primary care - mental health integration. Mental health services are often fragmented without appropriate supports in place for patients and families. Helpful tools for care providers include the Behavioral Health Integration Capacity Assessment and a discussion of how to enhance the coexisting general health and mental health care needs of patients with optimal efficiency and effectiveness


Older adults are another sub-population who may require a more integrated healthcare approach due to the acuity and complexity of conditions they may have. Addressing the needs of the frail elderly through a coordinated, multidisciplinary approach is required. Often, those with chronic conditions without adequate community support may present at the emergency department which can be detrimental from a cost and patient care perspective. Some examples of geriatric tools that can be used in the emergency department to properly assess patients at risk of poor outcomes and make the environment more senior-friendly include:


The following case studies offer useful examples of how some of the above-noted tools have successfully been implemented into practice:


A useful framework for integration of community and clinical care is also worth reading as it outlines a core set of preventive services with high economic value and health benefit for elderly patients with broader applicability to the general population. 

Focus on Transition Points Where Integration is Most Likely to be at Risk 

Fostering proper collaboration and communication during transitions of care is critically important. Examples of transition points include hospital discharge to home or other care settings. Useful tools in this regard include the IDEAL: Discharge Planning Strategy, to ensure patients and families have the information and skills required to take care of themselves when they leave the hospital. Quality improvement techniques such as process or value-stream mapping may be helpful in identifying bottlenecks and inefficiencies in discharge practices. The following 'How-to Guides' are useful tools to for improving transitions to both clinical offices as well as skilled nursing facilities to avoid re-hospitalizations. The use of evidence-based clinical practice guidelines such as Clinical Best Practice Guidelines: Care Transitions can also facilitate improvements in practice. 

Empower Patients and Families to Help Design a More Responsive System 

Patients and families are the best sources of information when it comes to what is working well and what isn't. Useful tools for organizations to access in this regard include the Guide to Patient and Family Engagement in Hospital Quality and SafetyWorking with Patients and Families as Advisors as well as a Gap Analysis to determine organizational readiness for patient and family engagement.

Make Integration a Strategic Priority Shared Collaboratively & Measure Achievements Regularly

Fostering relationships with other organizations, including care providers, suppliers, vendors, academia and private corporations may be worth exploring in order to develop innovative ways to integrate care. A useful example of a partnership strategy from Mount Sinai hospital demonstrates the need for organizations to look beyond their walls to identify partners who may further a shared vision. The public/private partnership (P3) model might also be worth considering in bringing additional stakeholders to the discussion. A useful case study that demonstrates how collaborative partnerships can be fostered to deliver patient-centered care and improve care coordination can be found here. In order to improve integration, measurement is a critical starting place. Metrics should be linked to a larger organizational or system-wide strategy where possible so that there are clear lines of accountability for performance. Tools such as the Balanced Scorecard can be useful in this regard.

Incent Providers and Organizations to Make Integration a Reality

Policy makers need to develop systems that provide the right mix of incentives for providers operating in siloed systems to work together collaboratively to improve integration of care.


Need more information? Have some resources to share? Please visit the Care Integration Community of Practice and ask a question in the discussion space and/or upload files to share with your colleagues.