Denver Health's success at integrated care lauded as 'learning laboratory'

Denver Health—Colorado's largest health care safety net provider—is being lauded as a model system for promoting a culture of continuous quality improvement, adopting new technology and incorporating it into everyday practice, taking risks and making mid-course corrections, and providing leadership with accountability. Because it has accomplished these objectives and others in a straightforward way that could be adapted elsewhere, the Commonwealth Fund is promoting Denver Health as a "learning laboratory."

Denver Health president Patricia Gabow, MD, tells State Health Watch the biggest issue for other jurisdictions wanting to learn from what Denver Health has accomplished is to find the political will that is needed to make changes. "So many groups that have come to visit us say politically they could never do it," she says. "As with so many other issues, we know what we should do and we just need to find the political will to do it. We've been very lucky here in Denver that we've always had the political will."

Denver Health is a comprehensive and integrated health care system that provides primary and specialty care, emergency medicine, and acute hospital care to residents of Denver and the Rocky Mountain region. Its mission is to provide access to quality preventive, acute, and chronic health care to all the citizens of Denver regardless of ability to pay; to provide emergency medical services to the region; to fulfill the community's public health needs; to provide education for patients and health care professionals; and to engage in research.

Denver Health serves some 25% of all Denver residents, including one-third of the children in the city. The organization is the largest health care safety net provider in the state and is its largest Medicaid provider. In 2005, uncompensated care provided by Denver Health totaled $285 million or 42% of total patient charges. As in many other safety net systems, Denver Health's population is largely uninsured and disproportionately comprised of members of minority groups.

Inherent tension seen

According to Dr. Gabow, the balance between individual community health center site autonomy and uniformity of system process is an inherent tension. She tells SHW that while administrative complexity could be an issue, Denver Health has been fortunate to have stable executive leadership. "Creating a system this complex from scratch is a challenge," Dr. Gabow says. "For someone trying to model our system, administration would be a challenge."

The single biggest challenge facing the system, Dr. Gabow says, is the ever-increasing cost of uncompensated care. But she says she remains convinced that to have high-quality, low-cost care, it is necessary to move to an integrated care model. Dr. Gabow concedes the system lacks some elements, primarily home health and long-term care components.

Commonwealth Fund program officer Rachel Nuzum, lead author on the Denver Health report, praised the system's integrated model. "What they are doing is consistent with what the Commission on a High Performance Health System is looking at in terms of a continuum of care," she tells SHW. "Some might argue that it's not good to have such a high percentage of uncompensated care patients in one facility, but Denver Health has found a way to make it work for them."

Among the key success factors in the Denver Health story, Ms. Nuzum says, are the commitment to information technology (IT), leadership from the top down that has involved all employees in continuous quality improvement, and a good understanding of the organization's target population.

"A comprehensive overall [system] is difficult without a leadership that is ready to take it on and go with continuous improvement," she says. "Patricia Gabow has been a huge driver in Denver Health's success but short of cloning her, we hope that as the stories filter out and others read about it, they will realize that it's not that different from where their institution is and will be interested in trying to follow Denver Health's lead."

In 2003, Denver Health started to transform itself and create a culture of continuous improvement. A Commonwealth Fund report says the organization adopted specific new processes and tools. Thus, it systematically applied the principles of "team manufacturing," based on Toyota's approach to streamlining its operations and eliminating waste. To develop appropriate in-house expertise, it invested in the training of 50 staff members in adapting industrial techniques to the health care setting. As a result, five strategic "value streams"—access, inpatient flow, outpatient flow, operating room flow, and billing—were selected as targets for the initial redesign effort.

One thing that sets Denver Health apart from some other safety net hospitals has been its willingness to build infrastructure for high performance in information technology and work force. Since 1997, the organization has invested $275 million in health-oriented information technology, which has enabled establishment of a centralized data warehouse that integrates both clinical and financial data and allows for standardized reporting. A single imaged electronic record format is used across the entire system so that any provider can retrieve a patient's information in real time.

Dr. Gabow tells SHW that when people 10 years ago talked about integrated delivery systems, they merged hospitals and bought medical practices. But that's not an integrated model, she says. "IT is very important to our seamless movement of care," she says. "Even though we are safety net providers, we've put $275 million into IT since 1997. We have a single imaged electronic health record across the whole system with a common patient identifier."

The investment in IT also is important, Dr. Gabow explains, because Denver Health is a teaching institution. A standardized approach of care, she says, can't be taught individually to each intern or resident. Rather, it comes through computerized order entry. And the only way to end health care disparity is through standardized care. "We know that 20% of all tests ordered are because the doctor didn't have information they need."

To ensure that it has a capable work force, Denver Health has implemented a four-part strategy including a talent bank, an interview tool that measures "talent intensities," training for key leaders regarding selection, and an employee-engagement survey.

While there are many factors that contribute to the overall high quality of care that Denver Health provides to its patients, the Commonwealth Fund Commission on a High Performance Health System cites these attributes that other health systems might consider replicating:

Denver Health is an integrated system, endowed with appropriate tools. An infrastructure exists to provide coordinated care to the community and there is a commitment to adopting new technology and incorporating it into everyday practice.

Denver Health provides a culture of improvement, peopled by dedicated staff. Decisions are data-driven and feedback loops allow for continuous quality improvement. There is willingness among the leadership to take risks and make midcourse corrections.

Innovation at Denver Health has strong support at the top. Leaders at Denver Health clearly communicate their vision that high-quality care derives from a high-quality system. The leadership and staff are bound by a common mission that reflects this vision. The leadership has adopted a market-based strategy with a clearly defined target population. Their approach, which requires strict accountability, aligns incentives to encourage the systems approach.

Despite many challenges, the report says, Denver Health remains fiscally sound and a leader in delivering health care. Although it is a safety net system, it is not a place of last resort, but rather a place of first choice. Denver Health has been named one of the top 50 hospitals in the U.S. in four of the categories in U.S. News & World Report's "America's Best Hospitals," and has received awards from numerous professional organizations for such things as information technology use and its efforts to improve immunization rates among low-income Denver children.

First steps to integrated system

In an article in the Jan. 21, 2003, Annals of Internal Medicine, Dr. Gabow said the first move to functional integration occurred when community health center internists and pediatricians began inpatient attending rotations and medical and pediatric residents were assigned to the large community health centers. Medical residents remained at the same clinic throughout their training. In 1998, a family medicine residency program was implemented with similar integration. These efforts, she said, created a new level of integration across the continuum of care.

Pharmacy services also were separated. A patient with a given diagnosis at the hospital campus community health center had access to different pharmaceutical agents than a similar patient at an off- campus center. To rectify that situation, a common pharmaceutical formulary was established for the community health centers and the hospital. Likewise, another area of separation was access to capital. Capital and construction dollars for the community health centers had been limited to the small amount in a federal grant. Under the reorganization, capital equipment for the entire Denver Health organization is prioritized by the senior executives during the budget process on the basis of need and strategic priorities.

"Denver Health is now fully integrated organizationally and functionally, horizontally and vertically," Dr. Gabow wrote. "The horizontal integration is achieved through one administrative team and shared processes and care protocols across all community health center sites. Vertical integration is achieved since the system links the emergency (911) pre-hospitalization service, a 349-bed hospital, 10 community health centers, 13 school-based clinics, public health department, substance abuse and mental health treatment, a poison center, an advice line, and a managed care insurance product. Physicians are key to the continuum of care. All full-time physicians at Denver Health are salaried employees, have hospital admitting privileges, and are faculty of the University of Colorado School of Medicine."

Primary care, including obstetric care and dental care, is available within Denver's medically underserved neighborhoods and most primary care visits occur within the patient's neighborhood. Patients also benefit from easy access to specialty care since all adult and pediatric medical and surgical subspecialty services are available at the hospital campus.

Download the Commonwealth Fund report at www.commonwealthfund.org/publications/publications_show.htm?doc_id=509163. Contact Dr. Gabow at (303) 436-6611 and Ms. Nuzum at (202) 292-6722.