Cross-Continuum Collaboration in Health Care: Unleashing the Potential

The growth of accountable care organizations (ACOs), bundled payment initiatives, and other performance-based payment arrangements signals a shift in the health care landscape toward rewarding value, rather than the volume of services provided. Although this shift is still unfolding, many health care organizations are adopting population health approaches that expand their focus beyond acute, episodic care, to ensure that relevant post-acute and primary care, as well as community services and supports, are available in a coordinated fashion to meet the needs of patients across the care continuum. However, creating effective linkages across the care continuum requires overcoming challenges related to the historic fragmentation of health care service delivery within most communities, in which provider organizations may not share a common mission, orientation to the goals of care, or information exchange platform. The need to bridge organizational boundaries is neither new nor limited to health care. Growing interest in the concept known as collective impact—defined as ‘‘the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem’’ —highlights the importance of collaboration in addressing complex social issues. This approach is considered particularly valuable for tackling ‘‘adaptive problems’’—such as those confronting cross-continuum teams in health care—in which ‘‘the answer is not known, and even if it were, no single entity has the resources or authority to bring about the necessary change.’’ Our combined experience studying and working with organizations engaged in readmission reduction efforts throughout the country has yielded valuable insight into effective mechanisms of collaboration among acute, post-acute, and community-based providers to identify and address coordination issues that span the care continuum. In this commentary, we summarize our learning about factors that facilitated successful cross-continuum collaboration, which helped improve care for individuals transitioning between care settings and highlighted how such efforts can help accelerate broader costand quality-related improvements. Enabling Factors for Cross-Continuum Collaboration