The final phase of the Pathway represents the culmination of the work of the previous phases, when the redesign experiments and their lessons and results become integrated into the ongoing work of the health system and its stakeholder organizations. Efforts have reached the Integrate Phase when there are established multi-stakeholder stewardship structure(s) that wield influence and hold authority for setting regional goals, for shaping and monitoring policies, for influencing and directing the allocation of resources and adjudicating conflicts among groups and organizations. This phase integrates the lessons of the prior phases in ways that facilitate ongoing learning and rethinking, enabling the system to adapt to changing conditions and to ever-heightened aspirations.
A successful Integrate Phase is characterized by stewardship groups that are widely viewed as legitimate authorities for identifying priorities and setting targeted goals consistent with a long-term regional vision. In Phase 5, financing has been fully redesigned. As the ReThink Health Dynamics Model shows, significant payment redesign toward value-based pay for health care and increased integration of health and social budgets accelerate the cost savings and health improvements realized by regional transformation efforts. The groups’ legitimacy derives, in part, from evidence of progress on health and care initiatives that show cost savings and health improvements across many initiatives. Transparency of data and shared metrics are critical underpinnings both to evidence of results and the continuing learning and adaptiveness of the collective effort. At the same time, a Phase 5 effort has broad and active resident engagement in the system that may be part of the stewardship structure, and they certainly are the key voices establishing vision and priorities for the system.
A few regional efforts are showing certain aspects of Phase 5 stewardship properties (though we have yet to see any wholly transformed health systems producing the results that characterize this phase). In one advanced stewardship example, recognizing that “only through a collective effort can meaningful change be realized in such a large and diverse region,” the County of San Diego Board of Supervisors launched Live Well San Diego in 2010 as a “long-term plan to advance the health, safety, and overall wellbeing of the region” that includes citizens, city and town governments, healthcare and other types of businesses, military and veterans organizations, schools, and community- and faith-based organizations. Today, every county department is involved in Live Well San Diego. This effort clearly derives its authority to steward the system from being an initiative of the county government in broad partnership with diverse stakeholders around the region.
By contrast, the Whatcom Alliance for Health Advancement (WAHA), in Bellingham, Washington, derives its authority not from local government, but from the credibility and respect it has built since 1985 as a non-profit deeply engaged with the community. Governed by a leadership board that includes concerned citizens and representatives from healthcare, public health, business, and governmental organizations, WAHA is a backbone organization that works hard to engage the community in everything it does and seeks to serve as the true community voice on healthcare priorities in the region.
Stewardship groups in the Integrate Phase have well-developed norms and procedures both for holding members accountable to shared goals and for respecting the values and role of different institutions. In this phase, there is widespread transparency among the key players about their goals, and their performance and contribution to collective aims. After the disruptive changes of Phase 4 have resulted in viable redesigns, the core strategy of a Phase 5 effort is once again continuous improvement and consolidation of learning, aimed at producing better and better results, with joint projects launched as the effort identifies new challenges or ways in which the results of the current system could be still better. Phase 5 regions have broadly implemented practices of shared risk among stakeholders in the health system, with residents and providers alike holding responsibility for results.
Further, in the Integrate Phase, funding streams are sustainable, with adequate short- and long-term private and public investments both for the upstream drivers of health and economic prosperity in the region, and high-quality, affordable care for residents. The Live Well San Diego effort is an important example of global budgeting for health and other social services in the United States. The structure allows the region to invest its resources more efficiently while achieving better outcomes—much like many foreign nations that spend less than the U.S. on health, but whose people enjoy better health status than Americans overall.
The Integrate Phase is only a stable equilibrium, however, if the stewardship of the health system in the region is attentive to ongoing changes in the environment, dexterous in in responding to those changes and attentive to influencing and sustaining a policy environment that promotes and protects a sound health system strategy over time.
Read the full descriptions of the Phase 5 Pitfalls.
Read the full descriptions of the Phase 5 Momentum Builders.
The ReThink Health Dynamics Model: Anytown
Examples of Stewardship Groups Exhibiting Characteristics of the Phase