What is the optimal organizational/ leadership structure to oversee population health and post-acute care in a large health system?

Over the past several years, I have observed many changes in creating the optimal leadership structure for population health and post-acute care services. To date, I have not found a very efficient and successful model. My observations are we tend to work in siloes, with communication challenges and team members across the system performing duplicative work. A successful program may exist already within the system to assist with a particular population, but other service departments are unaware and may look to use a similar product (basically re-start the entire process and not use all of the learning of the other department).

Our Home health program has a successful telehealth program in place for well over 13 years and markedly reduces readmissions at 30 days. Recently I learned of another hospital service department is looking at telehealth as a way to reduce 30 day readmission/ 90 day bundle readmission and. In our health system, I have been told by clinicians and patients that three different nurses have called on the same day to check on how they are doing. The first nurse is from the hospital unit, second nurse is from home health to set up the next visit and the third nurse is from the ACO.

I look forward to hearing any feedback, ideas or suggestions, which might assist us to enhance our services.



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Participant comments on What is the optimal organizational/ leadership structure to oversee population health and post-acute care in a large health system?

  1. I think the Module 3 paper “Transforming Care at UnityPoint Helath – Fort Dodge” by Amy Edmondson et al nicely describes the same problem. To create patient-centric care you have to break down the silos and design coordinated care. To start with you need a steering committee consisting of representatives from all stakeholder organisations (ie hospital, home health etc.) to lead the change. The same stakeholder organisations build working groups to redesign the treatment/care processes. Co-ordinating teams and a patient navigator are good examples how to to smooth the patient path. Also at our organisation we have good experiences to use Lean tools like A3 to improve our services and cut the waste. Having a special palliative care program helps to serve well also the sickest and support their families.

  2. As healthcare continues to merge and larger and larger organizations become the standard model this is a problem that will continue. Changing the nature of the overall structure of the organization will help “translate” services across silos. Often the dispirsment of “best practices” does not occur because the best practice requires additional inputs abover the current operating model and or the restructuring of work teams. Multiple structures can be employed to help address this issue. Having a central Project Mananagement Office that deploys project managers to assist end operating units would help translate established services through out the organization. If the end unit wants to impliment Telemedicine it would engage their region’s PMO coordinator who would help scope the project, determine deliverables and add consulting project manangement support and oversight. Part of the project would include the PMO asset surveying the organization for “existing or best practices” and then bring that information back to the requesting end entity. They would also bring back practice to the central PMO team. Additionally they would provide “expert” PMO support to end operating units.

    Around communications a single EHR that all business units use with an alert system that automatically pulls up patient touches in the last 24 hours to alert the provider. Also designated “patient reps” that have the responsibility for serving as the patient’s navigator for the whole organization who – following scripts – to primary communication and health coaching with the patients could help mimimize the multiple communications and also help keep patients within the health system.

  3. We are also in the process of restructuring to address this very issue. We’ve decided to establish a Triad leadership model to oversee all Community Based Care for our integrated healthcare system. The triad consists of a COO, CNO, and CMO. Under the leadership of this triad, we’ve placed our medical group, homecare, palliative care, the ACO, senior services, SNF relationships, and our wellness and health promotion strategy. It’s clear organizationally that this group has responsibility for delivering on our population health goals and they will direct all post-acute care activities and will be the decision makers on tools and platforms needed to support care.

    1. This is an innovative structure! Thank you for posting- I’ve learned more from the post than I will be able to contribute! Thank you all!

  4. Not surprisingly we have had similar challenges and have taken a like approach of getting all of the stake holders in a room to design care pathways. This sets forward a “playbook” that defines the individual roles and allows each group to understand what they do affects the individual patient. They key to being successful is to ensure there is one overall coordinating group, understanding the key driver of each group (& where possible letting them retain a piece of this if it make sense in the model) and tracking outcome data.

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