Looking for the Pathway to Integrated Care? Follow Your Front Line



Ask any experienced care or case manager about integrated care, and many will tell you that our healthcare system is not designed for the patient with complex needs or front-line staff in mind. Our system is built on a silo care approach, often to the point where we do not realize how fragmented we are. Care integration may often exist in individual settings, but it rarely exists in an active system beyond the distinct points of care. For example, primary care staff may take an interprofessional approach to integrate primary care. Nurses, social workers, providers, pharmacists, dietitians and other disciplines designated within the primary care setting actively communicate and collaborate with one another as a primary care interdisciplinary team. Specialty care and mental health staff take a collaborative care approach to integrate their own specialty or mental healthcare delivery. Care and case managers typically work with their interdisciplinary teams within their assigned setting or program, often missing an opportunity to integrate various care plans from the diverse points of care into a centralized plan for the patient.

Outside of the physical walls of our individual practice siloes, rarely do we see primary care teams actively collaborate or communicate with specialty care or mental health teams, besides through passive, written communication in the health record system. Daily operations and system processes often do not allow for team members from various settings to actively collaborate and communicate for integrated care planning, missing the opportunity for a seamless patient care experience. For many patients, this traditional approach to healthcare delivery may work and meet their needs as they are able to coordinate care between siloed practice settings themselves. However, for a small percentage of patients, this status quo system fails them and puts their safety at greater risks.

According to Ortaliza et al., “in 2019, five percent of the population accounted for nearly half of all health spending…at the other end of the spectrum, the 50% of the population with total health spending below or equal to the 50th percentile accounted for only three percent of all health spending” (2021). It is this top 5% of the patient population where our healthcare system is not designed to meet their bio-psycho-social needs that drive their poor health status and over expenditure of resources. Most, if not all, patients in this top 5% cohort tend to have more than one care or case manager assigned. But unfortunately, due to a disjointed system, even our care and case management practices tend to be siloed and fragmented, further aggravating the systematic problem.

For example, a patient who suffers from uncontrolled diabetes and bipolar disorder may also experience financial strain due to job instability and challenges with an ineffective social support network. A patient with complex needs tends to be involved with various specialty and/or mental health clinics, in addition to their primary care team. It may not be uncommon for this patient to have at least three or four care or case managers along the continuum. They may have an RN care manager assisting with diabetes management, who works with the specialty clinic interdisciplinary team. The patient may also have a mental health clinic RN case manager to assist with self-management of bipolar disorder and a separate primary care social work case manager to address social determinants of health. This multidisciplinary team approach may result in various siloed care plans addressing the patient’s multifaceted needs. Care and case managers are often focused on their area of expertise and plan care with their clinic-based interdisciplinary teams, missing an opportunity to deliver a centralized, integrated care plan to the patient focused on their whole health needs. Requiring intricate systems navigation, the patient with complex needs may become overwhelmed with the siloed, often competing care plans to integrate their own care coordination.

The system is seldom designed for effective and efficient cross-setting communication, many times missing an opportunity for integrated care planning. In the traditional care setting, care and case managers often work behind the scenes, focused on the key disease-specific or problem-focused issue(s). The care and case management systems typically rely on a push process of referrals for reactive patient identification, various setting-specific care plans, and passive communication through health record documentation, which misses an opportunity to integrate care planning for seamless patient experiences. Together, our patients and staff require integrated systems along the healthcare continuum for seamless communication, collaboration and coordination of care delivery and safer, more effective health outcomes.


An effective and efficient integrated care delivery system provides personalized, proactive, team-based care along a seamless continuum to meet the holistic care needs of each individual patient. But how does a healthcare organization transform into an integrated delivery system? According to Leslie Jurecko, MD, MBA, the chief safety and quality officer at the Cleveland Clinic Health System, “a change in one part of the system always causes a change in another part of the system…organizations are a system of interrelated processes. Improving complex systems is evolution — not revolution. Go slow with change, engage stakeholders early and anticipate how other parts of the system will be impacted” (Jurecko, 2021). In an ideal integrated care setting, the primary care team works with the specialized care and case managers assigned by key programs, usually within the same integrated healthcare system or as a partnership through an affiliation. However, due to the various system structures, the networking capacity of the primary care team is often stretched beyond feasibility. Just as the patients with the most complex needs may work with three or four different care or case managers at one time, the primary care team may have 30 to 50 different care or case managers to collaborate with across the various specialized programs. There is not a one-size-fits-all model to integrated care, and an organization should begin by assessing and identifying unique opportunities to develop a transformational plan to evolve into an integrated delivery system over time.

An effective integrated delivery system continuously redesigns the interrelated processes to foster a team-based culture and environment for seamless care delivery centered around the whole health needs of the patient. For example, as nurse managers of a case management and remote patient monitoring program in an integrated healthcare system, our team originally assigned new consults based on disease classification to deliver disease-specific case management services or on a chronological system for generalized case management services with remote patient monitoring support. Although these patient assignment methods allow for a specialized disease management approach for the case managers, this design adversely creates a siloed approach for both the patient and the primary care teams, with a missed opportunity for a team-based approach to integrated care delivery.

To solve this systems issue, as a shared governance unit committee, the front-line case managers decided to view primary care teams as key internal customers. This collaborative decision resulted in a fundamental practice change, beginning with the patient assignment process to align one case manager to a group of five to seven primary care teams. This redesign allows for the case manager to build a feasible network with their assigned primary care teams as opposed to a potential range of 30 to 50 different primary care teams depending on the breakdown of the caseload. Narrowing the case manager’s network also improves the experience of the primary care teams by allowing for a collaborative partnership with one case manager, as opposed to potentially having 10 to 15 different case managers from the remote patient monitoring program. In this system redesign, the case managers rely on creating interprofessional relationships to drive integrated communication and coordination of care along the continuum and at the point of delivery. Case managers collaboratively huddle with their primary care teams to actively communicate care planning needs and to scrub predictive analytical reports for proactive patient identification to optimize outreach, rather than relying solely on a reactive, referral-based process and passive electronic communication in the health record. For patients with complex needs who have multiple care or case managers assigned, a lead case manager is designated with the responsibility of guiding a team-based approach across the continuum to integrate the various care plans for shared decision-making and consistent messaging to the patient. Through a shared governance approach, our front-line team redesigned our siloed patient identification system to create a foundational, team-based environment to foster an organic, interprofessional culture focused on integrated care planning and whole healthcare for the patient.


How does an organization successfully integrate care delivery within their systems? Follow your front line by operationalizing a shared governance approach. According to Heather McKnight and Sheila M. Moore, with Texas A&M University in Texarkana, “improved patient outcomes are the most significant clinical impacts associated with a nursing shared governance structure within the healthcare organizations. Numerous studies have found improved results for nursing-sensitive indicators…using shared governance structure and processes” (McKnight and Moore, 2022). Allow those who do the work to lead the way in owning their practice. Staff who are engaged are more satisfied when they see their ideas and work drive system redesign and practice changes, strengthening their likelihood to achieve stronger and safer outcomes.

To operationalize a shared governance approach, an organizational structure supporting the shared decision-making between the front line and leadership must be established. Shared governance shifts the culture from a top-down, hierarchical management style to an open, communicative learning environment where collaborative, shared ownership between administration and front-line staff becomes the focus (McKnight and Moore, 2022). Our case management program established unit-based committees of front-line staff to redesign system processes and practice changes for an integrated delivery system. Front-line case managers and support staff also served as active members and/or leads for organizational committees overseeing care coordination and integrated care systems. Solid strategic planning for organizational transformation should include a thorough self-assessment of the current state of readiness to shift to an integrated delivery system. Areas of self-assessment include evaluating interrelated processes along the continuum that impact integrated care delivery. For instance, how good is the handoff communication process with key interprofessional teams along the continuum during vulnerable patient transitions? Do processes rely on passive, written communication or active, verbal communication? How are care and case management caseloads assigned? Does the system solely rely on a push process with referrals, or a pull process with predictive analytics, or a mixture of both? How well do primary care, specialty care, mental healthcare and other interprofessional settings communicate and collaborate with one another?

There is not a one-size-fits-all solution to integrated delivery systems as healthcare systems are structured differently, experience varying priorities and care for diverse patient populations. The key to success is to involve front-line staff in shared decision-making when assessing the organization’s current state, identifying and prioritizing opportunities for system integration and redesigning of systems and interrelated processes to improve the experience of the patients and staff in integrated care delivery. As Jurecko mentioned above, “go slow with change, engage stakeholders early and anticipate how other parts of the system will be impacted” (Jurecko, 2021).

For sustainment, a shared governance approach to the organization’s overall structure should be considered. For example, the organization may benefit from establishing an integrated care committee, with frontline leadership and involvement, to oversee, track and trend interrelated system processes for continuous improvement efforts and sustainable outcomes. An automated dashboard to reflect key quality indicators optimizes system redesign efforts and continuous improvements for sustainability. Transforming into an integrated delivery system involves both cultural transformation and systems redesign, where processes and pathways are redesigned to foster individual behaviors and practices collectively aimed at care integration throughout the continuum of care delivery.


As mentioned above, as nurse managers of a case management and remote patient monitoring program, our team took a shared governance approach to begin our organizational journey toward transforming into an integrated care system. Our front-line case managers led system redesign and cultural transformation efforts for stronger systems integration to yield higher quality and safer integrated clinical care. In the first two years, our team saw a 12% increase in nurse case manager satisfaction scores as 90% of the team ranked the organization as the best place to work. Out of over 350 patients surveyed, over 70% of patients reported having one case manager to lead integrated care planning improved their trust in the healthcare system, and 85% reported that shared decision-making and receiving a consistent message from healthcare teams improved. Once the team focused system integration efforts on inpatient transitions, there was an 11% improvement in overall patients rating their care transition experiences from an inpatient setting to an outpatient setting as highly satisfied.

When targeting the patient population at highest risk of a hospital admission or life-altering event related to a chronic condition and assigning a lead case manager, the team saw a decrease of avoidable admissions over a rolling 12 months from 1,115 patients to 973 patients, and the organization’s hospital-wide readmission rate dropped from 14.54% to 12.94% within a two-year period. By transforming to a proactive pull process for patient identification, the team successfully transformed the program’s targeted population. Before the transformational shift, approximately 30% of caseloads consisted of patients considered to be challenged with complex needs. After the shift toward an integrated care delivery system, over 70% of the caseloads consisted of patients with complex needs. This increased capture of patient complexity resulted in a higher reimbursed revenue for the remote patient monitoring program, as they captured over $6.3 million at the end of their third year compared to just over $2 million in their baseline year. If an organization aims to improve its costs of care, they should always begin first with focusing on the experiences of the patient and staff, along with quality of care.

In conclusion, to find your organization’s pathway for transformation into an integrated delivery system, follow your front line. There is no one-size-fits-all solution to integrated care delivery, as each healthcare system has its own unique needs and priorities. Operationalizing a shared governance approach is a solid method to successfully redesign systems and to transform culture and behaviors for stronger integrated delivery of care for our patients with the most complex needs. Patients with lower complexity of needs may be able to navigate the complex healthcare system to coordinate their care. However, for the highest-risk and highest-utilizing cohorts, these patients tend to have the most healthcare teams involved, making it even more challenging to navigate the intricate healthcare system to piece together various treatments for an integrated plan of care. By aligning systems to create a team-based approach for integrated care planning and by assigning a lead case manager to patients with the most complex needs, clinical care can be integrated along the continuum for safer transitions, improved experiences and higher quality of care delivery.

dorothy sanders

Dorothy Sanders, MHL, RN, CCMhas 19 years of nursing experience within the Veterans Healthcare Administration (VHA), the largest healthcare network in the nation. In 2016, as a field expert, Ms. Sanders was asked to help spread Integrated Case Management practice across the VHA enterprise. By 2021, Ms. Sanders became a national consultant to implement the innovative model across more than 90 healthcare systems and developed a digital roadmap for organizations to follow that includes five milestones to ensure full integration. Ms. Sanders currently works as the RN quality manager for the VHA National TeleMental Health Center.


Jurecko, L. (2021). 10 leadership mindsets for high reliability organizations: How to empower caregivers and engage patients in patient safety. Retrieved from https://consultqd.clevelandclinic.org/10-leadership-mindsets-for-high-reliability-organizations/.

McKnight, H. and Moore, S.H. (2022). Nursing shared governance. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK549862/.

Ortaliza, J., McGough, M., Wager, E., Claxton, G., and Amin, K. (2021). How do health expenditures vary across the population? Retrieved from https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#Proportion%20of%20individuals%20by%20health%20status,%202019.



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