Q&A: Using programs of care to reduce silos and improve patient outcomes

Q: Do you have any advice on how to collaborate across an organization to improve care for a specific patient population?

A: Programs of care can be used to govern clinical practice across time and place. A major restructuring using programs of care, also known as collaborative practice groups or self-managing teams, can move your organization in a direction that reduces silos and improves outcomes for your patients.

Programs of care are permanent interdisciplinary teams brought together to focus on the care provided for a specific patient population. The focus can be within or outside the organization, or both, based on the need of the population of patients being evaluated. The scope seems global, but the teams can and do look at the structure, process, and outcomes of patient care across the levels of care and for extended time frames into recovery. Their work may include reviewing and revising a single small task to solve a problem or development of a large program design, such as development of clinical pathways and/or orders sets.

The functions of programs of care in an organization include:

• Standardization of practice
• Evaluation of the continuum of care
• Quality improvement
• Evaluation of the flow of patients through the system
• Evaluation of care given
• Evaluation of data (core measures and HQI data included)
• Implementation of interventions to affect the outcomes of care
• Clinical pathway development and monitoring
• Use of evidence-based medicine

For more information, see Case Management Models: Best Practices for Health Systems and ACOs. 

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