Integrating Health Care Improvement Activities Across a Region, and Using the Health Department as the Ringleader

Health care for persons living with eventually serious chronic conditions necessarily entails multiple service providers serving a geographically-defined population. Health care reforms have focused on other issues, such as coverage, competition, and quality within one provider organization. Engineering shared processes, standards, and indicators among multiple provider organizations in a geographic area offers striking new opportunities for rapid improvement, and also new challenges and difficulties. Multiple national leadership organizations are sponsoring initiatives (including the Medicare QIOs' Care Transitions Project). In Washington, DC, the Public Health Department is leading the Chronic Care Initiative and this report characterizes the rationale, challenges, and tentative successes of using public health as the integrator of regional health care reform. The Chronic Care Initiative is building community capacity for evidence-guided tests of change. The emphasis on solving problems for the city requires community partners to shift from their usual focus upon filling gaps to learning how to test, maintain, spread, and sustain gains. The CCI is building indicators of progress for the city's care system and also is generating a community coalition that can advocate for measuring progress and ensuring investment. The Public Health Department turns out to have substantial strengths in reliability, continuity, intra-governmental partnerships with regulatory affairs, clinical services, environmental services, and other government entities. The Public Health Department also has challenges in allowing the community coalition to speak out on policy, in investing in indicators of progress for the affected population, and in using processes built for other purposes for this endeavor.