Competing health care systems and complex patients: an inter professional collaboration to improve outcomes and reduce health care costs

Competing health care systems and complex patients An inter professional collaboration to improve outcomes and reduce health care costs lable at ScienceDirect Journal of Interprofessional Education &[.]

Journal of Interprofessional Education & Practice (2017) 5e10 Contents lists available at ScienceDirect Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com Competing health care systems and complex patients: An inter-professional collaboration to improve outcomes and reduce health care costs Lauran Hardin, MSN, RN-BC, CNL a, b, *, Adam Kilian, MD a, c, Kristin Spykerman, MSW, CAADC d a Trinity Health-Michigan d/b/a Mercy Health Saint Mary's, Grand Rapids, MI, USA National center for Complex Health and Social Needs, Camden, NJ, USA University of Utah Health Care, Salt Lake City, UT, USA d Cherry Health Services, Inc., Grand Rapids, MI, USA b c a r t i c l e i n f o a b s t r a c t Article history: Received 10 July 2016 Accepted 20 January 2017 Background: High-need, high-frequency patients overutilize acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to US healthcare costs Purpose: Our objective was to reduce healthcare costs while improving clinical outcomes through optimizing healthcare delivery and inter-professional collaboration for complex patients Method: To so, we partnered with a competing health care system to address fragmentation in the patients' plans of care contributing to patterns of high utilization Discussion: Our collaborative approach was associated with a reduction in healthcare utilization and costs for this population, as well as an increase in operating margin Conclusion: Collaboration between neighboring competing health systems that share a select group of complex patients is an effective way to stabilize care, decrease health care system overutilization, improve healthcare delivery, and reduce the costs of associated care Our intervention model provides a useful model for inter-organizational collaboration in healthcare © 2017 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Keywords: Cross continuum care collaboration Competing health systems Integrated care High need patient High frequency patient Complex patient Chronic patient Emergency department Individualized care Decrease readmissions Preventable hospitalization Cost reduction Root cause Inter-professional team Interorganizational team Integrated behavioral health Overuse Overutilization Super utilizers Introduction Background Funding: This work is supported by an Innovation Grant funded by Trinity Health The funding organization(s) had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript Conflicts of interest: The authors declare that they have no conflicts of interest * Corresponding author National Center for Complex Health and Social Needs, 800 Cooper St, Camden, NJ, 08102, USA E-mail address: lhardin@camdenhealth.org (L Hardin) Interest in high-need, high-cost (HNHC) patients has intensified in recent years as healthcare systems increasingly focus limited resources on high-risk patients to prevent the unnecessary use of costly services.1,2 To meet the needs of HNHC patients, many organizations are developing specialized intensive management programs, offering enhanced clinical access, care coordination, medication reconciliation, support during transitions from hospital to home, and referrals to social and community services.3e6 http://dx.doi.org/10.1016/j.xjep.2017.01.002 2405-4526/© 2017 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) 6 L Hardin et al / Journal of Interprofessional Education & Practice (2017) 5e10 The most complex HNHC patients have a constellation of chronic disease, psychiatric diagnoses and substance use disorder Patients in this group are often dually eligible, having both Medicare and Medicaid, and they represent one of the highest cost groups in the healthcare system.7 The complex needs of the population are often beyond the management capabilities of a typical primary care practice Stabilization in the population requires an integration of disciplines traditionally separated by specialty and regulations that divide medical, psychiatric, and substance use information into disconnected documentation systems.7e9 Rationale for our intervention In response to the needs of this population, the Cherry Health Durham Clinic (CHDC) e part of the Cherry Health System e created an integrated Primary Care and Behavioral Health Medical Home (BHMH) specifically designed to meet the needs of patients with co-occurring disorders The CHDC opened in 2011 and includes a Primary Care Physician, Physician Assistant, Psychiatrist, Nurses, Health Coaches, and Supports Coordinator all in one office Patients are able to receive services in one location with integration of psychiatric and medical records Health Coaches provide support for on-going chronic disease management including evidencebased therapies for psychiatric and substance use disorders The Supports Coordinator addresses housing, insurance, and access issues for further stabilization Due to the comprehensive nature of services, the clinic receives some of the most complex patients in the city including patients with extreme healthcare utilization (>100 visits per year), complex psychiatric conditions such as Munchausen Syndrome, and very complex social situations such as homelessness, active domestic violence, and significant trauma In 2012, Mercy Health Saint Mary's (MHSM) e part of the Mercy Health System e began to investigate the HNHC population accessing the hospital system A Complex Care Center was created by a Clinical Nurse Leader (CNL) to provide clinical intervention, process improvements, and analysis of patients accessing the hospital Population analysis of high frequency patients in the system revealed an unexpected finding of patients assigned a medical home with a competing healthcare system but utilizing the Mercy Health hospital system for care One group included the Cherry Health System patients and this led to a new approach to care coordination We realized that to stabilize their care we would need to collaborate with our competitors Rather than focusing solely on improving care within the four walls of our own organization, we began to look at how we could collaborate across systems to bring the best of both organizations to the table to serve the needs of patients.10 The general aim of our model for inter-organizational collaboration was to create a continuum of care across organizational boundaries to deliver integrated healthcare to HNHC patients to reduce their need to overutilize healthcare resources Just as previously addressed by Loehrer et al, creating an effective linkage across the care continuum required “overcoming challenges related to the historic fragmentation of healthcare service delivery, in which provider organizations may not share a common mission, orientation to the goals of care, or information exchange platform.” Although we initially faced significant challenges to create the partnership, focusing first on the patients helped build bridges to improve outcomes for both organizations Challenges of inter-organizational collaboration Collaboration between organizations is often problematic due to different organizational logics and cultures,11 conflicting legislation, knowledge and value bases, and conflicting economic and other interests of the organizations involved.11e16 Yet, increased collaboration among different healthcare systems to prevent and manage chronic disease has been recognized as being critical for successful care of these patients.17e20 The Centers for Disease Control and Prevention (CDC) and the Public Health Accreditation Board (PHAB) have reinforced the vision for more unified chronic disease approaches across healthcare systems: two of CDC's four key chronic disease practice domains call on public health to improve the services provided by health care systems,18 and health care system collaboration is now required by PHAB for health departments' accreditation, and the movement toward collaborative chronic care continues to grow.19 In spite of the existence of many integrated care programs worldwide, ample literature published about inter-professional team-based care,21e24 and growing emphasis on these issues, there has been little published on interorganizational team-based care in the setting of competing health systems Specific aims The objective of this article is to describe our approach to inter-organizational collaboration on a shared population of HNHC patients, illuminate challenges involved and how to overcome them, share findings from the clinical impact of our collaboration, and describe the model that has been successful in our area The purpose of this article is to share the framework of our model, thereby providing a guide for facilitating interorganizational collaborative practice among competing health care systems to improve patient outcomes and quality of patient care Process of collaboration with a competing health system Here we outline the inter-organizational infrastructure and practices that we considered integral for facilitating effective cross continuum collaboration between competing health systems to help shared HNHC patients (Fig 1) Details on patient identification and root cause analysis are described in a separate article.8 Patient identification and root cause analysis Data analysis of the HNHC patients in the Mercy Health system built the case for collaboration by highlighting the need for improved care in the population The Complex Care Center utilizes a tool called a Complex Care Summary to analyze root causes contributing to patient destabilization.8 Collecting information about the patient's cross continuum team identified natural partners for collaboration including the CHDC Reviewing root causes beyond the medical diagnoses (including psychiatric, social determinants of health and system barriers) enabled us to build a comprehensive foundation on which to create the person-centered plan of care Organizing our collaboration around patient specific situations gave us the opportunity to build the collaboration around shared purpose Both organizations wanted to improve outcomes; however, the complexity of the patients made it difficult to achieve this in isolation Engagement of the clinical partnership Patient-centered collaboration proved essential Many models of inter-organizational collaboration begin with system leadership meetings and organizational infrastructure We found that by starting with the patient and their individual story we were able to quickly develop a shared sense of purpose to improve outcomes across organizations Rather than getting delayed by organizational L Hardin et al / Journal of Interprofessional Education & Practice (2017) 5e10 Fig Concept map for inter-organizational cross continuum collaboration between competing health systems politics and contracts, we were able to design the collaboration around the patients and their direct needs This naturally built bridges past competitive issues because we quickly learned that our inter-professional collaboration made each of us stronger and more able to meet complex patient needs Shared infrastructure We initially began one patient at a time but, as the population grew, building structural elements to facilitate on-going collaboration was important to consistently produce outcomes A Business Associate Agreement (BAA) was developed and described how information sharing between entities would occur for healthcare purposes HIPAA allows sharing of information for care coordination but this additional document was signed between our organizations to clarify the relationship.25 Integrated patient consent forms for medical and behavioral health information are another emerging tool for facilitating care for complex patients.26 CHDC utilizes this integrated consent form for their patient population which adds support to collaboration across organizations.26 Shared plans of care embedded in the medical record also proved crucial MHSM's created a tool called Complex Care Maps© to translate important patient information into the medical record.8 In a one page succinct format, root causes of patient instability, key strengths and challenges, the cross continuum team with contact numbers, evidence based considerations and key notes in the EMR are identified.8 This tool pops up with an alert the first time a provider opens the medical record during the episode of care.8 Collaboration occurred between the MHSM's staff and the CHDC staff to create Complex Care Maps© for their patients The hospital staff began to call the CHDC staff directly from the ED and the inpatient unit facilitating stronger integration and consistency of care across settings Facilitating effective team culture Clinical leaders of both interdisciplinary teams (MHSM CNL and CHDC MSW Director) needed to model collaborative behaviors and inter-professional respect to continue to build success within the teams We achieved this through adopting the facilitator role and shepherding the teams out of competitive waters and into collaborative focus on outcomes for the patient Leaders needed to take accountability for system failures in meeting patient needs and approach this topic with a sense of curiosity rather than blame For example, when we discovered that a root cause underlying destabilization of some patients was a change in psychiatric medications during a hospitalization that were long established in the outpatient setting, the response needed to be one of constant process improvement Leaders investigated more information about the root cause and brought key team members together to create process improvement infrastructures and on-going communication to prevent this from happening with subsequent patients Leaders consistently made the teams aware of targeted outcomes by addressing frequency of healthcare visits and status of progress in the shared plan of care If team members had not followed up on key elements, then leaders consistently held a sense of curiosity and inquiry around what the barriers were to achieving this for the patient Facilitating the removal of those barriers, rather than punishing or blaming team members, proved to be a major key to success and allowed the teams to learn how to collaborate with each other without high risk of failure Ongoing management Extending services outside the walls of our institutions also facilitated a great deal of trust between organizations The MHSM's CNL attended collaborative rounds every weeks at the CHDC to L Hardin et al / Journal of Interprofessional Education & Practice (2017) 5e10 show respect for the importance of the cross continuum team and to invest in on-going collaborative stabilization of patients When a CHDC patient was admitted to the hospital, contacts were made with the outpatient team and joint conferences were held in the hospital setting This continued to reinforce the importance of the primary care team as the “home” of the patient and stopped fragmentation in the plan of care by the inpatient team It also saved significant time for the case management team in the hospital by stopping “reinvention of the wheel” in the patient's care plan substance use disorder (53%), history of suicidality (42%), and complex social determinants of health issues including history of trauma (58%) and current homelessness (16%) Surprisingly, the population was primarily less than 50 years old (68%) Many had a pattern of high frequency healthcare access for multiple years including 26% with four or more years of >3 healthcare visits (IP or ED)/year and 25% with greater than years of frequency prior to intervention Joint celebration of success Capturing successes was important for continuing to motivate the teams to attend to the challenging work of culture change and retaining resiliency in the face of some of the most difficult patient situations in the healthcare system Reinforcing the principle that change occurs in iterations in complex populations and acknowledging incremental shifts in outcomes as a win was an important principle Traditional outcome measures such as reduction in visits, reduction in length of stay, and adherence to primary care appointments were reviewed Successes such as MHSM's ED staff calling the CHDC staff during the moment of care or CHDC staff visiting the patient in the hospital and conferencing with inpatient staff were also acknowledged Most importantly, leaders needed to model that successes would be shared between organizations, rather than attributed to one organization, to continue to foster the inter-organizational partnership (Fig 2) In the 12 months prior to intervention, patients averaged 12.42 ED visits, 3.37 IP admissions, 14.21 Length of Stay (LOS) days, and 2.21 CT scans per patient per year In the 12 months after intervention, patients averaged 8.89 ED visits, 1.68 IP admissions, 7.21 LOS days, and 0.74 CT scans per patient per year This represents a decrease in average ED visits by 28%, IP admissions by 50%, LOS by 49%, and CT scans by 67% Of note, the population of 19 patients had 396 hospital visits (ED/IP/OP) in the 12 months prior to intervention CT scans are specifically called-out in the results section as the risk for over-testing in the population is high due to frequent healthcare access Gross charges in the population decreased $721,654 dollars in the 12 months after intervention, representing a 51% reduction in gross charges Similarly, direct expenses decreased $211,129, representing a 54% reduction in direct expenses Operating margin improved $84,774 in the 12 months after intervention, representing a 71% increase in operating margin despite the reduction in visits to the hospital Impact Lessons learned Utilization, cost, social, and healthcare access variables were collated from the electronic medical record and cost accounting system; a comparison of the 12 months prior to and the 12 months after introduction of the collaboration was conducted This project was deemed as a Clinical Quality Improvement Initiative by the Mercy Health IRB, and as such was not formally supervised by the IRB per their policies Recognizing and overcoming cultural barriers to interorganizational collaboration Subject population and setting Nineteen patients who regularly accessed care at MHSM's and were patients of the CHDC between November 2012 and July 2015 were served during this collaboration Both agencies are urban healthcare providers and are located mile apart MHSM's has greater than 80,000 annual ED visits and Cherry Health serves more than 60,000 complex patients in a competing healthcare system The population served had a prevalence of psychiatric diagnoses (100%), Fig Collaborative rounds at CHDC Outcomes of collaboration Despite the above infrastructures and practices designed to promote effective team culture, inter-organizational partnership can present unique challenges as barriers arise and it is important to be aware of and overcome them The well-known saying, “Culture eats strategy for breakfast”, attributed to Peter Drucker,27 is a key concept when considering inter-organizational collaboration Competitors not often come together to solve problems The business infrastructure that fuels competition is organized around preservation of financial resources Often, the first cultural hurdle that arises in collaboration is mistrust and financial competition Starting with the patient story and the opportunity to improve quality and safety for a person helped to jump this hurdle Healthcare providers overall have a shared cultural value to heal and improve patient outcomes Leaders needed to proactively model and address fears and misconceptions that quickly arose to test the strength of the commitment to collaborate For example, as the partnership became more visible in the healthcare system, a concern was brought forward that the CHDC was sending all of their complex and uninsured patients to MHSM's and directing their patients with insurance to another healthcare system This fueled the barrier of mistrust and fear about financial resources Leaders quickly investigated the rumor and brought forward data analysis that showed there was no diversion of patients occurring and the majority of patients served by the CHDC had marginal insurance This changed the rumor and helped people see that we actually had shared financial benefit from working together to stabilize these HNHC patients A second key cultural barrier to overcome can be a lack of understanding the different functions and applications of teambased vs individual-based care delivery When you organize L Hardin et al / Journal of Interprofessional Education & Practice (2017) 5e10 care around the patient story, key relationships quickly emerge For example, the hospital staff may perceive that they are the key driver of the plan of care but their contact with the patient is limited to the silo experience of the time the patient is in the hospital The long term relationship of a primary care physician, psychiatric case manager, guardian or other discipline may be the most effective role to have long-term communication and coaching directly with the patient for a plan of care In order to effectively work with a team approach, each person needed to be ready to let go of being “the one” person to affect the plan of care and face his/her own feelings of competition for credit in improving outcomes For many providers, this is an unfamiliar role and independence is more comfortable, but less effective for the patient Leaders needed to continuously model the question “who has the strongest relationship with this patient” and also continuously facilitate hearing from every discipline on the team what else they might collaboratively contribute to improving outcomes for the patient A final key cultural barrier to navigate is complexity avoidance, sometimes also called approach-avoidance conflict A state of ambivalence, anxiety, or fear can arise when confronted with a complicated situation that is desirable to resolve but involves addressing undesirable aspects of the human condition.28 When hearing of a burning building, it would be a rare first reaction to run in among the flames and try to fix the problem; working with complex patients is no different Ethical complexity and longterm trauma were common in the population served in this collaboration Leaders needed to model a state of support and safety for providers to express their fears and uncertainty in complex cases that touched on their own personal issues or were beyond the team's capacity to understand how to resolve Uncertainty partnered with curiosity needed to be an accepted state and cultural value Leaders were charged with continuously bringing-in additional resources to help solve complex situations and creating a state of curiosity rather than failure when an immediate solution was not apparent Concluding remarks Collaboration between neighboring competing health systems that share a select group of complex patients is an effective way to stabilize care, decrease healthcare system overutilization, improve healthcare delivery, and reduce the costs of associated care Our intervention model provides a framework for interorganizational collaboration in healthcare In health systems around the world, the focus of current reform efforts is to achieve higher quality, more cost-effective care.29 Policymakers and leaders are beginning to converge on a core set of solutions, most of which call for increased coordination among care providers across professional boundaries.10 Next steps After successful implementation with the CHDC, Mercy Health has continued to seek additional partners for collaboration within the Clinically Integrated Network as well as outside of it Collaboration is designed around the complexity of patient needs, utilizing the same framework but applying it in a range of approaches from weekly rounds with a Federally Qualified Health Center serving the homeless population to monthly “huddles” for more stable populations Such relationships may be facilitated by the creation of financial incentives that reward coordination, such as creating a payment mechanism/platform to encourage competitors to form partnerships/relationships, understand their shared patient population, explore the breakdowns in care in their community, and implement complementary improvements in each setting of care.10 The nation would benefit from learning about the experiences of additional approaches to cross-continuum collaboration as health reform continues to unfold.30 Acknowledgments Authors would like to acknowledge: Diana Mason, PhD, RN, FAAN and Jean Barry, PhD, RN, NEA-BC for serving as advisors Views expressed are those of the authors and not necessarily those of MHSM's, CHDC, or the University of Utah References Silow-Carroll S, Edwards JN Early Adopters of the Accountable Care Model: A Field Report on Improvements in Health Care Delivery New York, NY: The Commonwealth Fund; 2013 Hasselman D Super-Utilizer Summit: Common Themes from Innovative Complex Care Management Programs Hamilton, NJ: Center for Health Care Strategies, Inc; 2013 Zulman DM, Ezeji-Okoye SC, Shaw JG, et al Partnered research in healthcare delivery redesign for high-need, high-cost patients: development and feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT) J Gen Intern Med 2014;29(suppl 4):861e869 http://dx.doi.org/10.1007/s11606-0143022-7 Yee T, Lechner A, Carrier E High-intensity primary care: lessons for physician and patient engagement Natl Inst Health Care Reform 2012:9 Peterson K, Helfand M, Humphrey L, Christensen V, Carson S Evidence Brief: Effectiveness of Intensive Primary Care Programs, VA-ESP Project #09-199 2013 Bodenheimer T Strategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on Pioneering Programs Center for Health Care Strategies, Inc; 2013 Peterson Center on Healthcare Issue brief: improving healthcare for high-need patients In: Models of Care for High-Need Patients: A National Academy of Medicine Workshop Sponsored by the Peterson Center on Healthcare Washington, DC: Keck Center of the National Acadmies; July 7, 2015 Hardin L, Kilian A, Muller K, Callison K, Olgren M Cross-continuum tool is associated with reduced utilization and cost for frequent high-need users Western J Emerg Med 2017;18(2) http://dx.doi.org/10.5811/ westjem.2016.11.31916 Hardin L, Kilian A, Olgren M Perspectives on root causes of high utilization that extend beyond the patient Popul Health Manag September 2016 http://dx.doi org/10.1089/pop.2016.0088 10 Boutwell AE, Johnson MB, Rutherford P, et al An early look at a four-state initiative to reduce avoidable hospital readmissions Health Aff (Millwood) 2011;30(7):1272e1280 http://dx.doi.org/10.1377/hlthaff.2011.0111 r A, Blomberg S, Hasson H Implementing a continuum of care model for 11 Dune older people-results from a Swedish case study Int J Integr Care 2011;11:e136 12 Glendinning C Breaking down barriers: integrating health and care services for older people in England Health Policy 2003;65(2):139e151 13 Meyer JW, Rowan B Institutionalized organizations: formal structures as myth and ceremony Am J Sociol 1977;83:340e363 14 Bate P Changing the culture of a hospital: from hierarchy to networked community Public Adm Rev 2000;78:485e512 15 Hall P Interprofessional teamwork: professional cultures as barriers J Interprof Care 2005;19(suppl 1):188e196 http://dx.doi.org/10.1080/135618 20500081745 16 Axelsson R, Axelsson SB Integration and collaboration in public health e a conceptual framework Int J Health Plann Manage 2006;21(1):75e88 17 Institute of Medicine Primary Care and Public Health: Exploring Integration to Improve Population Health Washington, DC: National Academies Press; 2012 http://www.iom.edu/Reports/2012/Primary-Care-and-Public-Health.aspx Accessed 11 June 2016 18 Chronic Disease Prevention and Health Promotion Domains National Center for Chronic Disease and Health Promotion Centers for Disease Control and Prevention; 2012 http://www.cdc.gov/chronicdisease/about/foa/docs/FourDomains-Nov2012.pdf Accessed 11 March 2016 19 Standards and Measures: Version 1.0 Public Health Accreditation Board; 2011 http://www.phaboard.org/wpcontent/uploads/PHAB-Standards-and-MeasuresVersion-1.0.pdf Accessed 11 March 2016 20 Stine NW, Chokshi DA, Gourevitch MN Improving population health in US cities JAMA 2013;309(5):449e450 http://dx.doi.org/10.1001/jama.2012 154302 21 Minkman MMN, Ahaus KTB, Huijsman R A four phase development model for integrated care services in The Netherlands BMC Health Serv Res 2009;9:42 http://dx.doi.org/10.1186/1472-6963-9-42 10 L Hardin et al / Journal of Interprofessional Education & Practice (2017) 5e10 22 Van Raak A, Mur-Veeman I, Hardy B, Steenbergen M, Paulus A Integrated Care in Europe: Description and Comparison of Integrated Care in Six EU Countries Maarssen: Elsevier Gezonheidszorg; 2003 23 Billings J, Leichsenring K Integrating Health and Social Care Services for Older Persons: Evidence from Nine European Countries Hants: Ashgate Publishing Limited; 2005 24 Provan KG, Nakama L, Veazie MA, Teufel-Shone NI, Huddleston C Building community capacity around chronic disease services through a collaborative interorganizational network Health Educ Behav 2003;30(6):646e662 http:// dx.doi.org/10.1177/1090198103255366 25 (OCR) O for CR Business Associate Contracts HHS.gov http://www.hhs gov/hipaa/for-professionals/covered-entities/sample-business-associateagreement-provisions/index.html Published 21 May 2008 Accessed 12 June 2016 26 Michigan Department of Health and Human Services Michigan Behavioral Health Standard Consent Form http://www.michigan.gov/mdhhs/0,5885,7-33971550_2941_58005-343686–,00.html Accessed 12 June 2016 27 Culey S Leadership and Culture: Part e The Case for Culture The European Business Review; May 20, 2012 28 Reddy S When patients are a pain for their doctors Wall Street J http:// www.wsj.com/articles/when-patients-drive-their-doctors-crazy-1459793860 Published April 4, 2016 Accessed 16 January 2017 29 Gittell JH, Godfrey M, Thistlethwaite J Interprofessional collaborative practice and relational coordination: improving healthcare through relationships J Interprof Care 2013;27(3):210e213 http://dx.doi.org/10.3109/13561820.2012.730564 30 Loehrer S, McCarthy D, Coleman EA Cross-continuum study panel Crosscontinuum collaboration in health care: unleashing the potential Popul Health Manag 2015;18(5):317e319 http://dx.doi.org/10.1089/pop.2015.0005  ... knowledge and value bases, and conflicting economic and other interests of the organizations involved.11e16 Yet, increased collaboration among different healthcare systems to prevent and manage chronic... group of complex patients is an effective way to stabilize care, decrease healthcare system overutilization, improve healthcare delivery, and reduce the costs of associated care Our intervention... facilitating interorganizational collaborative practice among competing health care systems to improve patient outcomes and quality of patient care Process of collaboration with a competing health system