Many integrated care measures identify populations based on cost/utilization rates or by identifying “those who actively use” emergency care. But some health systems are working to better identify people with complex medical and social needs in order to develop individualized interventions for targeted populations.

During a recent webinar, leaders from Kaiser Permanente, CareOregon and New York City Health + Hospitals shared their experiences trying to better understand populations and develop models of care that improve care for people who face a combination of medical, functional, behavioral and social needs.

The webinar, which was coordinated by Better Care Playbook and made possible through a collaboration of the Seven Foundation, was led by Michelle Wong, MPP, director of the Institute for Care Management at Kaiser Permanente, who described current work at the Kaiser Permanente complex. It takes initiative.

Because Kaiser Permanente is an integrated system with a health plan, medical group and hospitals in eight different regions, it’s a complex ecosystem, Wong said. “We feel that this integration and complexity uniquely positions our organization for learning, and that, as with our organization, there is a need to address the intersections in our complex patient needs.” She said KP is working to eliminate the silos between these organizations to improve health care delivery. “At the Institute for Health Care Management, we have a saying: we have to do the right thing easier. We focus on understanding what our patients with complex needs need to do, and then on creating systems that make it easier for our practitioners to do the right thing.”

KP’s approach is to create a portfolio of learning activities that are always connected to practices, medical teams and patients. The health system has a research unit called CORAL (Collaboration in Integrated Care: Operations, Research and Leadership) that brings together KP researchers with operational leaders to gather actionable evidence to improve integrated care.

CORAL tests and evaluates patient-centered interventions and systems at Kaiser Permanente and in partnership with outside organizations to develop the field and evidence base for integrated care.

“This approach to learning has been focused on supporting local teams, connecting them to each other and often complementing them with support such as assessments, patient and provider ethnographies, standardized screening and care plan tools, and staff competencies and training,” Wong said. Research plays a critical role in this approach to training and highlights how their thinking has evolved, she said. It has helped them move from the earliest concepts of high utilization of the 1 to 5 percent to more nuanced thinking about the integration of social/behavioral functional needs, and now to working on how to think more clearly about population identification. “We’re still learning at Kaiser,” Wong said, “but we strongly believe that connecting research with operations and our care teams and our patients in both directions will be critical for us to learn how best to provide care. . “

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