High-quality care

How an integrated care program can improve health care outcomes and reduce costs

David M. Smith, DO, shares how his integrated care program in Melbourne, Florida, has reduced its patients’ ED visits, hospitalizations and readmissions.


Today’s health care landscape is fraught with barriers to meeting patients’ needs. Time constraints in traditional practices can affect the quality of patient care, which, in turn, may increase cost burdens on practices, hospital systems, insurance companies and patients. With the average age of the population increasing, so too are the number of chronic conditions. Patients are increasingly showing up to outpatient and inpatient settings with complex medical histories, and they often need multiple medications and procedures.

Alleviating the burden

Factors that fall under the umbrella of the social determinants of health can also drive up costs. These may include medication costs, copays for medical visits, lab and imaging costs, the ability to travel to appointments, family dynamics and other factors.

It can be a daunting task for one practitioner to navigate these complexities and provide care. An integrated care program (ICP) can provide an additional layer of care that helps improve patient outcomes and reduce costs.

I have been a practicing osteopathic primary care physician in the Brevard County, Florida, area for over 30 years. For the last three years, I have been a member of an ICP of a major health care system in Melbourne. The ICP is a collaboration between the health plans and the medical group.

Team-based approach

The focus is on the approximately 6% of patients that are responsible for 35% of total costs. Patients are selected for admittance to the program based on specific criteria, which may include number of hospitalizations, emergency department visits, number and cost of medications, number of specialists and total cost of care. There is no cost to patients who are admitted to the ICP, and the program is 100% funded by the health plan.

A team approach is crucial to the success of the program. Patient care is coordinated through interaction between physicians, advanced registered nurse practitioners (ARNPs), pharmacists, social workers, nurses, case managers and medical assistants. Each patient is assigned a case manager who typically contacts the patient every two weeks, or more often if deemed necessary. Patients are typically seen every six weeks, or more frequently depending on their needs. For the initial visit in our program, typically 90 minutes are set aside so that someone from each discipline can interact with the patient and gather information.

During the initial visit, goals are set with the patient and barriers to those goals are assessed. Subsequent follow-up visits are typically scheduled for one hour and may involve one or more disciplines. Each day, a morning huddle meeting is held involving all of the disciplines. During this meeting, we discuss every patient on the schedule for that particular day.

In addition to daily huddles, a weekly multidisciplinary meeting is also held to discuss selected patients with more complex issues and to develop care plans for these patients. If a particular patient requires a more in-depth discussion, a complex case conference can be scheduled. Ideally, a complex case conference will involve all of the disciplines within the ICP as well as the patient’s primary care physician and specialists.

All patients in our program who are admitted to the emergency department or the hospital as an inpatient are scheduled for a post-admission follow-up visit as soon as possible. During these visits, medications are reconciled by both the physician or ARNP and one of our pharmacists. A root cause analysis is performed by the team in an attempt to reduce the number of future admissions.

As a proactive measure to reduce hospital admissions, we encourage patients to contact the ICP or their primary care practitioner for non-emergent issues. A large part of our job is to educate patients on the appropriate use of medical resources. Generally speaking, ICP clinicians are more accessible for patient visits and can see them in a timelier manner than clinicians in traditional practices.

Positive results

Outcomes for the ICP have been favorable. Over the ICP’s last fiscal year, we have shown a 57% reduction in inpatient hospitalizations with 66% less readmissions. There has been an 18% drop in emergency department visits. The overall cost per patient was reduced by an average of 38%, comparing pre- and post-ICP enrollment.

Our integrated care program is structured in such a way as to provide the highest quality of care while reducing costs. It does not replace a primary care physician or specialist, but rather facilitates the joining together of different disciplines to address the shortcomings of our current health care system.

In many ways, the holistic approach that the ICP practices mirrors the principles and practices of osteopathic medicine. Being a DO myself, I have found that the ICP fits with my background and philosophy of practice. Beyond the one-dimensional treatment approach that is all too often practiced, an ICP gives the clinician the opportunity to mine the underlying causes and contributing factors that ultimately determine health outcomes. Having other disciplines to collaborate with at a moment’s notice allows the practitioner to offer the patient a comprehensive health assessment at each visit. Also, the ability to take the appropriate amount of time to address all of the issues that factor into a patient’s overall health is invaluable.

As members of our integrated care program, patients are treated as whole individuals, with all of the complexities and nuances that that entails. This approach to health care is exactly what the osteopathic medical profession is all about.

Editor’s note: The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

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