Frank deGruy, MD, MSFM Chicago, 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

     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

     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

      Diseases vs. people Mind from body Patients from clinicians Clinicians from communities Generalists from specialists Patients and clinicians from purchasers from payers from policymakers

     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

   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

     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

  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

     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

 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

     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

 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

A new group wants to jump to solutions But a wise convener leads them through the U To a realistic shared solution

C. Otto Scharmer (2007); Theory U

Thanks to Gary Oftedahl for the Theory U diagram

Productive levels of distress in human systems

Limit of tolerance

Productive Range

Threshold of learning

Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 .

Technical vs. Adaptive Work

Adaptive Challenge

Limit of tolerance

Productive Range

Threshold of learning

Technical challenge Time Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

Keep in mind the social geography of your project!