Case Study: Integrated Delivery in Primary Care in the United States
By Hao Yi Tan
Overview of Intermountain Health
Intermountain Healthcare, headquartered in Salt Lake City, Utah (USA), is a well-regarded integrated health system recognized internationally. It operates 33 hospitals, including a virtual hospital, along with 385 ambulatory care centers. Intermountain also created SelectHealth, an insurance company that is a wholly owned subsidiary of Intermountain Health
Known for its excellence in clinical outcomes and cost-effective healthcare delivery, Intermountain Healthcare is the largest provider in the Intermountain West region of the USA, employing over 60,000 caregivers across seven primary states: Utah, Idaho, Nevada, Colorado, Wyoming, Montana, and Kansas. While primarily serving these regions, Intermountain Healthcare also extends its services to patients from other areas within the Intermountain West. In addition to its physical facilities, Intermountain Healthcare offers extensive telehealth services, boasting over 35 telehealth programs in the western United States. This strategic approach allows the organization to extend quality medical care to patients across a wide geographical area.
Delivery Integration in Intermountain Health
Intermountain Health primarily uses bold care model innovation and technology-driven initiatives to integrate care at the system level. In particular, they emphasize centralized control over their healthcare facilities, and use a wide array of technologies to integrate health data and provide care to patients. In addition, Intermountain has strong primary care base, with models of care that go far beyond the traditional solo GP office.
Vertical Integration of Care
‘One Intermountain’ Organizational Strategy
In the past, Intermountain Health managed its assets across four distinct regions delineated by geography. However, they made the decision to consolidate Intermountain Health into a singular, integrated system in 2017 (1). Under the new directive, Intermountain Health reorganized its operations to function as one cohesive entity, overseen by the system's executive leadership team. The primary objective of this restructuring was to streamline operations and enhance patient care delivery. Intermountain Health established a system-wide structure consisting of two principal groups: the Community Care Group and the Specialty Care Group. The Community Care Group assumes responsibility for maintaining community well-being through preventive measures and the provision of high-quality primary care services. This includes ensuring individuals receive essential health screenings, vaccinations, as well as support for managing chronic conditions such as diabetes. Additionally, outpatient treatments for minor medical concerns are administered through this group. Conversely, the Specialty Care Group concentrates on delivering specialized medical services and hospital-based inpatient care. Its primary objective is to ensure that patients receive appropriate care tailored to their specific needs, precisely when they need it. Intermountain Health conceptualizes this integrated system as "One Intermountain", emphasizing a unified approach to integrated care delivery (2).
Digital Health and Health Information Technology (HIT) Integration
Intermountain has historically capitalized on its strong technological background in order to leverage new technologies such as digital health and telehealth. They have made several key moves in the HIT space to ensure that their delivery system is not only integrated, but allows for additional uses such as patient interaction and geographical reach to provide primary care at remote areas (3).
Consolidated EHR across Intermountain Health
Intermountain Health has recently announced its implementation of an Epic based EHR system across its organization by the end of 2025, aiming to enhance interoperability and improve the overall patient experience (4). This decision was made after extensive input from healthcare professionals within the organization, and will unify the EHRs across Intermountain’s facilities. The transition to a unified EHR platform is expected to yield significant cost savings and facilitate better care coordination through improved data sharing and interoperability capabilities. Intermountain's choice of Epic as its EHR system provider is based on Epic's robust functionality and high satisfaction scores reported by facilities in Colorado and Montana already using Epic EHR, which exceed the national average.
Intermountain Health’s informaticists have also pioneered a novel, interoperable technology platform, aimed at improving clinical decision-making through real-time clinical support tools (5). These tools leverage evidence-based medicine, algorithms, and AI applications to assist medical providers in making more accurate diagnoses and treatment plans for patients directly at the bedside. The core of the platform relies on a standards-based workflow engine that brings together several services, including: Fast Healthcare Interoperability Resources (FHIR)-based read and write services that securely access and update the EHR in real-time; event processing through publish and subscribe mechanisms, ensuring continuous updates to the workflow engine as new test results are incorporated into the patient’s medical record; AI-powered imaging services for interpreting chest images using a deep neural network; and diagnostic services executed by an AI-driven Bayesian network.
Unified Patient Portal
Intermountain Health has introduced a comprehensive patient portal that amalgamates various health management tools into one convenient platform, accessible as a mobile app or website (6). This new portal consolidates and supersedes previous versions like My Health+ and the SCL Health app. The portal simplifies healthcare management by enabling users to schedule appointments, access health history, pay bills, manage family appointments, communicate with healthcare teams, view visit summaries and test results, manage medications, find providers, access Connect Care, use the Symptom Checker, receive preventive care reminders, estimate healthcare costs, and more. It aims to streamline the healthcare experience, making it easier for individuals and families to lead healthier lives by centralizing all health-related tasks and information in one place.
Use of Telehealth in Remote Areas
Intermountain Health has leveraged telehealth services to bridge the gap between healthcare providers in rural areas and patients in need of specialized care (7). The primary aim is to ensure that patients can receive high-quality specialty care without having to leave their local communities, thereby reducing the costs associated with patient transfers, expediting access to specialty treatments, and aiding community hospitals in retaining patients. These telehealth services encompass a wide range of specialties, including Infectious disease and antimicrobial stewardships, critical care monitoring, medical oncology, behavioral health and crisis care, newborn critical care, neurology and stroke care, pediatrics, and wound care.
This utilization of telehealth to integrate care across geographical distance is especially beneficial for populations that historically lack access to specialized care, contributing significantly to promoting equity across urban-rural divides (8). Patients receive the same standard of care from specialists, regardless of whether they are situated in a rural primary care clinic or an urban tertiary hospital. Moreover, telehealth plays a crucial role in addressing workforce shortages in rural communities and serves as a sustainable population health strategy, enhancing both the quality of healthcare and cost-efficiency.
By eliminating the need for costly patient transfers, telehealth reduces healthcare costs per capita, while also enabling local providers in rural areas to treat more patients (9). This, in turn, supports the viability of smaller hospitals and primary care practices, which are strategically vital for rural communities' overall health infrastructure.
Centralized Strategy for Patient Load Balancing
Intermountain adopted a strategy to centralize the management of patient transfers across its facilities by partnering with TeleTracking, a company specializing in a patient tracking system that integrates with Electronic Health Records (EHRs). Through this collaboration, Intermountain effectively utilized real-time data for load balancing, ensuring appropriate patient care while optimizing resource allocation (10).
Intermountain centralized its transfer center operations after initially outsourcing them. This shift allowed for greater control over patient intake processes, reducing treatment delays and addressing frustration among referring providers. They focused on creating system-wide situational awareness by centralizing operations related to patient transfers, placement, transportation, and virtual care in a single center. This approach facilitated cohesive workflows and improved understanding of patient demand and capacity across the system. Intermountain also improved physician interaction during patient transfers by addressing communication gaps and establishing protocols for structured patient assessments and decision-making, particularly for critically ill patients.
Intermountain leveraged technology to do all this, specifically TeleTracking's operational platform, to automate workflows and gain actionable insights through tools like SynapseIQ® Enterprise and TransferCenterIQ™ module. These technological advancements enabled better decision-making regarding patient care and resource allocation. Additionally, Intermountain enhanced access and triage processes by introducing a single phone number for patient transfers and consultations, which are then triaged by registered nurses and assessed by Tele-ICU physicians for appropriate patient placement. Furthermore, standardizing workflows and data analytics processes allowed Intermountain to improve efficiency and make informed decisions based on accurate and actionable data from TeleTracking's platform. This standardization also facilitated the identification of trends for continuous process improvement. Overall, Intermountain's efforts in system-wide load balancing led to significant improvements, including reduced stress on tertiary sites, faster response times, and enhanced patient care.
Integrated Primary Care
Reimagined Primary Care (RPC)
In response to the challenge of managing risk for populations, Intermountain adopted an enhanced primary care approach known as RPC in 2018. This strategy utilizes EHR and insurance claims data to facilitate seamless care transitions, minimize unnecessary follow-up care, pinpoint coding and care gaps, and tailor outreach efforts for high-cost care utilization. Intermountain implemented RPC through a phased rollout, starting with four clinic locations in 2018 and expanding yearly. RPC utilizes EHR data for timely insights into patients' healthcare utilization and integrates claims data to identify areas of low-value care. This integration offers valuable insights for each RPC team to pinpoint at-risk patients, address unmet needs, evaluate care gap closures, monitor performance indicators, and validate cost-saving measures. RPC implementation has resulted in increased provider engagement and improved patient experience scores compared to non-RPC providers within Intermountain Healthcare. Additionally, RPC patients showed significant reductions in emergency department visits, inpatient admissions, specialized nursing facility discharges, and overall costs when compared to a matched control group, highlighting the substantial value and potential cost savings associated with RPC implementation (11).
Mental Health Integration into Primary Care
To further improve the effectiveness and integration of primary care, Intermountain Health pioneered a program called Mental Health Integration (MHI) (12). Besides co-locating mental health services with physical health services, MHO emphasizes a comprehensive team-based approach. Primary care providers aimed to integrate and normalize mental health discussions within routine health exchanges, and fostered collaboration amongst primary care providers, specialists, patients and families. Through standardized protocols and electronic records, MHI ensures holistic care planning and improved patient access. Patients enrolled in Mental Health Integration (MHI) programs reported significant improvements in their relationship with caregivers and overall functioning in their lives. Staff delivering care through MHI noted improved access to mental health services, enhanced patient productivity, and increased utilization of team-based care, showcasing the potential of MHI in enhancing treatment outcomes and reducing costs for chronic diseases.
References
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