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Frank deGruy, MD, MSFMChicago, IL
June 22, 2011
From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together
Clinical Integration Vertical Integration
Population served Diversity of patients
By problems By payer
Diversity of practice forms Press of practice & competing demands PCMH & team-based care External collaborations
For PCPs with single or simple payer mixes
For “private” practices Consultations and referrals according to
matrix Upgrade in-house resources IPA-type solutions Other
Fast success, fast failure
Guidelines Implementation Sustainability
What do we pay for? Office visits Procedures For only some problems
What should we pay for? Health! Health care
Collaboration, integration Innovation
Measure health, healthcare, and cost outcomes
Pay for good health—within limits Pay for quality care Pay patients for participating Pay for partners to practice together Stop paying for bad care
That is fragmented & redundant Stop paying for too much care
Health Plans are architects: try new designs
Clinical integration Professional culture & practice style Communication Team-based care Operating principles adopted by ICSI
Independence of thought Diversity of opinion Decentralization of authority Ability to aggregate & share learnings
Vertical integration The role of the convener Adaptive vs. technical problem Solutions for complex problems & Theory U
• Loose connections
• Mapping (linking)
• Passion
• Emotional intelligence
• Trust in process
• Inspiration
• Tolerance of ambiguity
• Hands off approach
• Receding
• Backing away as work advances
Adapted from “The Starfish and the Spider”(Ori Brafman)
And--pointing at the “pole star”
Adaptive Challenge is complex Need to address & change deeply held beliefs &
values Loss is an inherent part of process Can’t be achieved within present system—people
must acquire new capabilities
Technical Problem is well defined Answer can be found within present system—
requires application of abilities already in it Implementation is clear
C. Otto Scharmer (2007); Theory UThanks to Gary Oftedahl for the Theory U diagram
A new group wants to jump to solutions
But a wise convener leads them through the U
To a realistic shared solution
Productive Range
Threshold of learning
Limit of tolerance
Time
Ten
sion
of
chan
geProductive levels of distress
in human systems
Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.
Productive Range
Threshold of learning
Limit of tolerance
Technical challenge
Time
Technical vs. Adaptive WorkAdaptive Challenge
Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.
Ten
sion
of
chan
ge
Keep in mindthe social geographyof your project!