Clinical Integration

For many who work on the front lines of delivery system reform, clinical integration is not a generic phrase to describe health care professionals working more closely together. It’s a specific type of arrangement that allows physicians to collaborate on improving quality and efficiency, while remaining independent entities.

In a clinical integration organization, physicians collectively invest in IT infrastructure, such as disease registries and clinical performance management systems, as well as funding staff dedicated to performance improvement. Participating physicians also commit “sweat equity” to improving performance—serving on committees as well as changing their day-to-day clinical practice. And they create explicit plans for how the network will improve care outcomes and efficiency.

Community Medical Group’s (CMG) patient-centered Clinical Integration (CI) programs foster continuity and communication across medical disciplines. These programs include standardized care protocols based on up–to-date evidence-based guidelines and best practice recommendations for assessment, testing, management, follow-up, and referrals.

In the past year, CMG has reached out to engage the full continuum of care with our Care Transitions CI program, which includes community pharmacists, skilled nursing facilities, the Yale-New Haven Hospital Emergency Department, local urgent care centers, and visiting nurse services providers in protocol development. Our Diabetes program will further span the healthcare continuum.

Our website will incorporate, protocols and guidelines and will be the means by which our providers communicate and exchange clinical information securely.

CMG’s data warehouse collects claims data from the payers and provides data-driven decision support at the point of care. In addition, these tools enable assessment of our CI programs, allowing us to determine the degree and quality of patient engagement and the patient experience.

Our focus on coordinating patient care across clinical conditions, healthcare providers, and settings enables CMG to excel at providing patient-centered, high quality, effective and efficient care.

Clinical Integration Committees

Clinical Integration Program Committees

Clinical Integration Steering Committee — This committee oversees all of CMG’s Clinical Integration committees.

  • Adult Medicine — Current programs exist for Diabetes, Heart/Stroke and Chronic Kidney Disease New programs are being developed to address generic medications usage and appropriate evaluation of headache/back pain.
  • Behavioral Health — The Behavioral Health committee is focused on improving the treatment of depression in the primary care setting, and appropriate diagnosis and management of ADD in our pediatric population. The committee collaborates with behavioral health consultants to improve the overall care of patients with the diagnosis of diabetes and degression.
  • Care Transitions — The Care Transitions committee has the broad charge to improve the management of our patients as they make transitions through different points of care delivery. This committee focuses on hospital admissions, readmissions, and appropriate emergency room utilization. A program in appropriate management of Congestive Heart Failure (CHF) is under development.
  • Pediatric Asthma — The Pediatric Asthma committee is focused on integrating asthma guidelines in pediatric practices with electronic health records.  The committee is developing quality measures for pediatric asthmas patients and hospital admissions.
  • Radiology — The Radiology committee’s focus is to create clinical practice guidelines for imagining for headaches and lower back pain, as well as on the utilization of imaging.
  • Surgery — A Surgery committee focuses on issues concerning managing surgical patients in the community setting. The committee developed guidelines to improve the quality and efficiency of pre-operative evaluation.
  • Urgent Care — The Urgent Care committee builds relationships between primary care practices and select urgent care centers.
  • Women’s Health — The Women’s Health committee focuses on developing guidelines for the appropriate screening for breast and cervical cancer and the appropriate use of HPV vaccination.

Resources:

2017 Clinical Practice Guide for Non-Pregnant Adults with Diabetes Mellitus

2016 CMG Clinical Practice Guide for Pediatric Asthma