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Silos in care are not breaking down fast enough across the continuum.
This was nearly the unanimous sentiment among the attendees at our CONTINUUM conference last week. When we polled the audience, 85% of respondents said that silos are not breaking down quickly enough, and this sentiment was reflected throughout the day’s panel discussions.
There are various reasons why integration across the continuum is moving too slowly, including a lack of financial alignment between payers and providers in value-based models, operational and financial pressures preventing care providers from innovating, and lack of technological interoperability.
However, the most significant impediment to integration and innovation across the continuum can be summed up in one word: mindset.
At least, this was my impression, coming away from the event. Executives with senior living operators, insurance companies, technology providers and deal brokers all zeroed in on the issue of entrenched mindsets either preventing progress altogether, or being the most difficult but important challenge to overcome in efforts to create more cross-continuum integration.
In this week’s exclusive, members-only SHN+ Update, I analyze this issue and offer key takeaways, including:
- Moves to create “narrow continuums” through M&A are occurring but challenging
- New terminology is needed to create “mindshifts” for better value-based care models
- R-H-I-P offers framework for achieving such mindshifts
The mindset problem
Many times over the past decade of covering the sector, I’ve heard forward-thinking leaders in senior living, skilled nursing, in-home care and other segments trying to convince their peers leading other organizations to change their mindsets, and take steps to position their businesses to provide more integrated care under value-based payment models.
But there now seems to be more widespread agreement at the leadership level – among providers and investors – that the future lies in greater integration. I believe this consensus is reflected in dealmaking.
A whopping 97% of CONTINUUM attendees who responded to our poll said they expect cross-continuum dealmaking – such as insurers acquiring providers, or one type of provider acquiring another – to increase in 2024.
Often, these types of deals aim to create a “narrow continuum,” said Dexter Braff, founder and president of health care M&A advisory firm The Braff Group, in a presentation that kicked off CONTINUUM. He defined a narrow continuum as one that involves, say, all the major varieties of at-home care. A single buyer might bring together Medicare-reimbursed home health, private-pay home care, hospice and home infusion into a single entity, to be able to control and coordinate the provision of these services, often with the goal of driving outcomes and controlling costs to win patient volume and financial incentives under value-based payment arrangements.
“We see this happening a lot, this is definitely happening,” Braff said at CONTINUUM.
Creating a narrow continuum certainly is a more straightforward proposition than creating a wide continuum, which Braff defined as one that brings various types of providers – home care, senior living, skilled nursing, senior-focused primary care, etc. – under the same umbrella as, say, an insurance company and acute-care providers.
But Braff warned of the difficulties in creating even a narrow continuum via acquisitions.
“Integration is hard to begin with – now imagine integrating three different types of companies that have been working as a silo since their [founding], and now you’re telling them, don’t silo anymore, work across these lines, and the culture is just resistant to that, because it’s not the way they’ve operated,” he said. “It is extremely difficult to get that type of integration and cooperation amongst these distinct product lines through an acquisition – it’s possible, but it’s difficult.”
This was the first reference at CONTINUUM to this problem of shifting ingrained mindsets, but it was far from the last. Mona Siddiqui, SVP of clinical operations for Humana’s Home Solutions business, also spoke to this issue.
Prior to her role with Humana, Siddiqui was the first-ever chief data officer at the U.S. Department of Health and Human Services (HHS), where she led an effort to integrate tech across different agencies.
“When I did this at HHS … the biggest challenge was culture; the technology was probably the last thing I worried about,” she said. “… Because if you’ve done the same thing the same way for 20 years, changing the way you do it, there’s this enormous amount of inertia, and I think that’s the thing that we have to fight the most.”
Lynne Katzmann, CEO of senior living provider Juniper Communities, also zeroed in on the mindset issue with regard to technology. While lack of interoperability remains a hurdle to care integration, there is “light at the end of the tunnel” thanks to efforts that have been directed toward solving this problem, including more effective middleware – but having these solutions will not be enough.
“It’s not just technology that makes the system work, it’s workflows, and it’s the mindset of the people involved,” she said. “Technology will not work if the humans involved, at least at this point, don’t know how to use it, don’t want to use it, and will not work with it in a meaningful way that gives you the outcomes you need. Mindset is a big part of that.”
In fact, mindset change is such a focus for Katzmann that she has developed and is refining a list of the “top five mindset shifts” that she believes are needed, and she said that she will soon be ready to share that list publicly.
Joel Theisen, CEO of Lifespark, said that the interoperability situation is “way better than it was five years ago, 10 years ago,” and he agreed that the bigger concern lies in shifting mindsets in order to operationalize new solutions.
“It’s truly the cultures of organizations that have been embedded in their own infrastructure, embedded in their own payment methodology,” he said, regarding the impediments to change.
Such sentiments were repeated in other forms and formats throughout the event, more frequently than I was expecting. All this focus on shifting mindsets and company culture suggests to me that the rubber is meeting the road more forcefully when it comes to cross-continuum integration. Whether it’s disparate providers trying to come together and integrate to create a continuum for the first time, or pioneers like Juniper and Lifespark taking the next steps in innovation and broadening their value propositions, there is an increasingly pressing need for shifting people’s mindsets across companies’ org charts – and across health care writ large – to achieve faster and more comprehensive results.
Changing a company’s culture is a notoriously difficult endeavor, but there were some concrete ideas put forward at CONTINUUM.
Katzmann and Theisen highlighted the importance of being deliberate and creative in speaking about where health care is headed in the future, and the role that new terminology can play in changing mindsets.
This point stood out to me and also powerfully struck Scott Tittle, managing director and head of government relations and external affairs at VIUM Capital, and former executive director of the National Center for Assisted Living (NCAL). Tittle spoke at CONTINUUM, and in his most recent “Two Minutes with Tittle” video segment, he shared some of his key takeaways from the event – and (perhaps unintentionally) introduced another term that I find useful: “mindshift.”
“I thought it was really fascinating that they focused on the vocabulary that we need to start using, to be sure that we’re mirroring and honoring that mindshift,” Tittle said, referring to Theisen and Katzmann.
I would argue that new vocabulary not only “mirrors” necessary shifts in mindset, but actually helps create these shifts. It’s a point that Katzmann made, in explaining why she coined the term “wellspan” and is urging its adoption beyond Juniper.
“What’s cool about wellspan is that it’s a new word, it takes you out of the traditional idea [of healthspan or lifespan],” she said. “And as health care providers, as payers, as participants in serving older adults, we need to think differently.”
Briefly defined, wellspan means “living longer, better,” Katzmann explained. (Those interested in learning more can read our past coverage here.)
Theisen also put forward some new terminology, noting that Lifespark does not conduct “assessments” of residents but rather conducts a process of “discovery.”
“We discover what’s important around wellness, and what drives their sense of wellness and well being,” he said. “And that’s really important, I think, to get it right, to build the trust and ultimately deliver on the options and services that we have the ability to deliver on.”
Also, Theisen explained that Lifespark made a major investment – he estimated $30 million – into the data and data architecture that supports an “electronic life record,” which serves the function of a traditional electronic medical record while also incorporating the more holistic information gleaned through the “discovery” process. The idea is to have a more comprehensive understanding of residents, in order to more effectively support their wellness; this in turn is crucial to achieving the outcomes – such as reduced hospitalizations – that are so important to Lifespark as an entity that assumes full global risk within value-based payment models.
At CONTINUUM, Theisen and Katzmann agreed to adopt each other’s language. The terms “wellspan” and “life record” are related, of course, in that they refer to a more holistic and long-term approach to resident wellness and care, rather than one that is more episodic and purely clinical. And these terms also reflect a preoccupation that Katzmann and Theisen have with understanding their residents (and beneficiaries) as living, breathing people who have autonomy, goals and needs that aren’t honored by typical approaches to health care, or the language that commonly focuses on only a particular element such as physical health.
“That’s what’s, I think, missing – we miss the actual person we’re trying to serve many times in our models, because we get enamored with our own business case,” Theisen said.
Katzmann argued that centering consumers and creating a “mindshift” among them also is crucial to forging a more integrated system of care and services for older adults. While Katzmann teased her idea of five mindset shifts, she did reveal one of these shifts at CONTINUUM, saying:
“We’ve been talking about government, we’ve been talking about payers, we’ve been talking about providers, we need to add consumers, consumers need to be citizens. They need to not only have a right to health care and services, they need to have a responsibility for helping to maintain it. And in my mind, that shift, as much as it will be painful to have those conversations, is critical for our ultimate success.”
Their words came back to me a few days after CONTINUUM, when I was listening to a Planet Money podcast about why so many doctors still use pagers. The episode focused on an effort at a San Francisco hospital to replace pagers with a secure messaging app. The initiative got off to a great start, showing promise in reducing patient wait times in the emergency room. However, the effort ultimately failed, in large part because physicians were resistant to actually utilizing the new tech.
I think that leaders in senior living who are pushing for new care models could learn from this example. Michaela Kerrisey, a professor of management at Harvard, spoke on the podcast about a mnemonic she uses with students to explain why such efforts commonly fail: RHIP, standing for risk, habit, identity and power.
Any successful attempt at a “mindshift” within an organization basically must address all these factors. In switching from pagers to a smartphone app, one risk was that phone batteries die more quickly than pager batteries. The switch also changed the power dynamic at the hospital by lowering the barrier to contacting residents – the most junior doctors – and thus increasing their workloads. The effort also ran up against identity-related issues, as using a pager is considered by some doctors to be a marker of their profession.
I wonder if the initiative would have been more successful if those leading the effort had more effectively put patients at the center, and appealed to doctors’ identities as healers by showing how the messaging app could improve outcomes. Taking this approach – putting the resident at the center, and appealing to workers’ “caregiver” identity – I think would be wise for senior living operators trying to implement new technologies and processes, including those related to more integrated, cross-continuum models.
RHIP is one model that could help providers achieve the new mindset that is needed to integrate at a faster pace and succeed in the difficult task of creating continuums, whether narrow or wide. And organizations that are not convinced about the importance of “mindshift” as the continuum continues to transform might soon be dealing with a similar but shorter acronym: RIP.