Project 2.a.i - Create an Integrated Delivery System Focused on Evidence Based Medicine and Population Health Management

Why FLPPS Chose this Project

Across the FLPPS region, widespread system-level gaps have led to inappropriate utilization of services and poor health outcomes for the Medicaid and uninsured population. Fragmented clinical services have led to high disease prevalence, poor health outcomes and siloed delivery of care for complex patients with chronic disease. Addressing these conditions through an integrated delivery system should result in improved outcomes for these individuals and reduction in preventable hospital utilization.

Delivering accessible high quality care in the right setting,
at the right time, at the appropriate cost.

What Success Looks Like

A highly-functioning Integrated Delivery System (IDS) should provide patients with access to high-quality primary care which connects to a continuum of care that is patient-centered and transfers the skills needed to manage an individual’s health care and health outcomes.

The keys to reducing hospitalization and long-term care are keeping individuals healthier longer, avoiding acute crisis through monitoring and proactively managing the individual’s physical and behavioral health, and coordination with the social services they require.

While Integrated Delivery Systems can be structured a number of ways, from multispecialty group practices with a loose hospital affiliation to fully integrated delivery and financing systems, successful IDSs share a number of common characteristics:

  • Network of Providers and Partners
  • Provide Comprehensive Services across the Continuum of Care
  • Embraced Patient-Centered Approaches to Care Delivery
  • Willing to Share Risks and Incentives
  • Connected via Advanced Information Technology

Providers and community health workers, working together to engage patients and coordinate and manage their care, will create healthier, happier, and more satisfied patients, faster recovery for those who are ill or hospitalized, improved quality of life and lower health care costs.

FLPPS recognizes that the long-term viability of the IDS is contingent upon its ability to successfully navigate changing paradigms, which include:

  1. Transition from the treatment of acute illness to the management of chronic disease,
  2. Integration of Health Information Technology (HIT), and 
  3. The critical need to reduce cost while improving both quality of care and patient outcomes.