**5. Integrated practice units**

An integrated practice unit (IPU) is a multispecialty team that collaborates to provide the best outcome to the patient at the lowest cost. These IPUs are encouraged to compete among themselves for the best possible outcome at the lowest cost during the cycle of care. The IPU will treat not only the disease but also all related conditions of the patient.

The team is responsible for the patient's full cycle of care. That encompasses outpatient, inpatient, rehabilitation, and supporting services such as nutrition, social work, and others. The team is also accountable for the outcomes and costs.

Usually with IPUs, we have faster treatment, better outcomes, and lower costs. All that are achieved by the amount of patients they are able to see.

Since the IPU focuses on disease, it is not clear how a patient with multiple diseases at the same time, and not necessarily correlated, will be conducted. Does he have to seek multiple IPUs to treat each of his diseases or only the one? Some say that the need to go to multiple IPUs may cause almost the same problem we have in today's system.

The West German Headache Center can be considered an IPU. It includes neurologists, physical therapists, and psychologists who work together to treat every patient. The patient sees all experts they need in a single visit. If diagnostic imaging is needed, it is obtained from a nearby partner provider [19].

Care delivered in an IPU should be structured. Just the fact that everybody is in the same place does not mean it works well and is integrated. The creation of evidence-based guidelines will incrementally improve value to patients.

One important thing for an IPU is volume. Volume is needed to achieve better results and improve value to patients. The more you study and the more you treat a disease, the better you get at it. Experience is a key point for the deliverance of value. With that you can incorporate more parts of the cycle of care in your facility.

The creation of an IPU can be challenging. A good example of how to make it work is as follows. The Navy launched in Jacksonville at their hospital a value-based program. They selected four of the most common condition to be the starting point [20]. A physician and a nurse were selected to lead each of the four IPUs that were created, and then they recruited other physicians, physical therapists, nurses, and others to be on the IPU. The teams received training on VBHC by external experts and the entire hospital too. Evidence-based treatment and outcomes were defined for later examination; the location, structure, and schedule were also defined by the team. The IPUs met weekly to monthly to discuss patients and treatments. When a treatment was not working, the team would come to an agreement to change it [20]. Three out of the four IPUs created were successful.

Another example of an IPU is at the Dell Medical School at the University of Texas. The musculoskeletal group implemented an IPU team. They followed these steps. First, they choose a condition, symptom, or patient segment to focus. They choose lower extremity joint pain. Next, they set the standards to meet for the patient to be able to go back to primary care. The next step is to define the clinical and nonclinical staff of the IPU, such as the IPU multidisciplinary team and the physical location of the IPU, for example, the building they are located. For their lower extremity joint pain IPU, all patients were initially evaluated by a mid-level orthopedic provider and if surgery was as option they would consult with the orthopedic surgeon and address any questions of the patient. All decisions were discussed with the patients as a shared-decision making. Data collection and feedback is an important step in an IPU since those measurements will be used to address the value of care. The final step is to identify opportunities to improve value to the patient, increasing the overall health and maintaining the patient engaged in care [21].

This is the basic structure to initiate an IPU at your local hospital to get started. At first, we can select a few specific conditions, the most common ones. Later, when you have the first data collected and analyzed, if they are successful, others IPUs can be created. For the data collection and patient information to be readily available, we need the implementation of information technology, such as electronic data records.

We will cover this topic of the collection of data next.

#### **6. Primary care**

Primary care is essential for healthcare. Primary care physicians are hard to find, and when patients do, they feel frustrated with the ability of primary care to meet their needs. The problem is that primary care needs to be organized to deliver and demonstrate measured value [22].

Primary care needs to be deconstructed. Instead of one single set of services, it is actually a group of services delivered for multiple subgroups of patients [22]. Like VBHC is organized around conditions so should value-based primary care. It will be needed to transform care into subgroups of patients with new ways of measuring outcome and costs, new payment models, and new approaches to integrate primary care with specialty care [22].

The problem with primary care is that the patients are heterogeneous. The diversity of needs these different patients create is the challenge to implement value-based primary care. It is impractical to measure outcomes achieved relative to costs for such diverse patients [22]. There are five elements to shift primary care to a value-based model [22].

The first element is basing primary care on patients' needs. It is to group patients by their needs. It is designed to create value to patients. The "needs" include types of services and effective methods for patients to access care [22].

The second element is integrating delivery models by subgroup. Once the subgroups are defined, we can move over to the second element. A few questions must be answered. First, the team should be composed of the physician and other personnel according to the subgroup and their needs. Second, the facilities should also be organized around the subgroup and their needs, and they can be arranged to each day of the week to receive a different group of patients. Third, providers must function as teams, a leader must be recognized, and the team must meet regularly to address the patients' needs [22].

The third element is measuring value for each patient's subgroup. Identification of the outcome that matters to patients is key; also, the measurement of the total

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their needs [22].

*DOI: http://dx.doi.org/10.5772/intechopen.93378*

fied and the costs ascertained.

**7. Information technology**

patient electronic data record, is so important.

value-enhancing IT platform for the IPUs [15].

nurse staff, physical therapists, and so on [15].

export when needed across the entire system [15].

record. Access is not limited to the IPU team leader [15].

correct measurement of outcomes [23].

cost should be done, including those costs outside primary care. All of the care processes must be mapped by subgroups; then, the resources needed can be identi-

fee-for-service payment could be available for patient's acute care need [22]. The final element is integrating subgroup teams and specialty care. Some patients will need coordination between primary care and specialty secondary and tertiary care. Healthy children and adult may have all their needs met by primary care. Chronic conditions will need to be integrated with specialty care according to

will revise this topic on information technology up next in further detail.

The fourth element is aligning payment with value. The payment system should be redesigned to a time-based bundled payment or a payment for a total package of services for a defined primary care subgroup during a specified time period. Additional

This concept of organizing care around subgroups may seem different than the purpose of primary care but this approach is something that will make primary care more efficient, integrative, and holistic [22]. Electronic data record systems are needed in primary care also. All the participants of the teams must have access to it, and it must be integrated with secondary and tertiary care units and their IPUs. We

All over the world the interest in VBHC is growing. With this growing interest and rapid acceptance of both patient and providers, it is important to have the right tools to record and analyze patient's data toward a value-based model. That is why the implementation of a value-enhancing information technology system, such as a

It is critical for the implementation of value-based healthcare to be successful such as the use of electronic data record. The completion of data and reduction of the potential loss of data, by not keeping patient paper records, are critical for the

Some electronic records today are very good for keeping data but make it hard to export those records for later analysis. There are six elements that are key for a

First, the platform must be centered on the patient. The system needs to follow the patients across the services and through time for the full cycle of care. Data are aggregated around the patients not locations. So, all parts of the team have access to the same and complete records, instead of the physicians having access only to his notes or other physicians' notes, he is capable of accessing the records from the

Second, it needs to use common data definitions. The data fields related to diagnose, medical history, and other aspects of care are standard according to the condition being treated so everyone can understand what it means and it is easy to

Third, it encompasses all types of patient data. Notes, images, laboratory tests, and many other are stored in the same place and in a standard format. Like said before, everybody has access to everybody's notes and to the complete patient

Fourth, the access is available to all parties involved in care. That means that the data collected have to be available to the patients and any referring physicians. The best information technology system possible is the one in that the patients can schedule appointments, refill their prescription, and communicate with their physicians and to the rest of the IPU team, in a simple and easy way. It also should

#### *Value-Based Healthcare DOI: http://dx.doi.org/10.5772/intechopen.93378*

cost should be done, including those costs outside primary care. All of the care processes must be mapped by subgroups; then, the resources needed can be identified and the costs ascertained.

The fourth element is aligning payment with value. The payment system should be redesigned to a time-based bundled payment or a payment for a total package of services for a defined primary care subgroup during a specified time period. Additional fee-for-service payment could be available for patient's acute care need [22].

The final element is integrating subgroup teams and specialty care. Some patients will need coordination between primary care and specialty secondary and tertiary care. Healthy children and adult may have all their needs met by primary care. Chronic conditions will need to be integrated with specialty care according to their needs [22].

This concept of organizing care around subgroups may seem different than the purpose of primary care but this approach is something that will make primary care more efficient, integrative, and holistic [22]. Electronic data record systems are needed in primary care also. All the participants of the teams must have access to it, and it must be integrated with secondary and tertiary care units and their IPUs. We will revise this topic on information technology up next in further detail.
