This post was co-authored by Chris Esguerra, MD, MBA and Collaborative Consulting’s Lori Peterson.

Whether you’re staying true to the Triple Aim or grappling with the Affordable Care Act’s uncertain future, addressing the unique needs of an aging population or partnering to deliver more coordinated care in your community, one thing is for sure – there has never been more change and uncertainty in healthcare than there is right now. To thrive in this uncertain, increasingly complex landscape, health and social organizations need a new type of leader: the system leader who is not only capable of driving their own organization’s success but is committed to being a catalyst for positive change across the entire healthcare ecosystem. This may sound like a tall order, but the good news is that anyone in any organization can be a system leader.

What Is a System Leader, Exactly?

Traditionally, leadership tends to focus on an individual’s personal attributes and how these attributes affect their ability to move a particular organization forward, regardless of the ways in which this progress may affect the success of other organizations with similar missions. In contrast, system leadership is a decision to be continually aware of and responsive to the dynamics influencing an entire ecosystem of inter-related organizations, for the sake of actualizing the potential for better outcomes.

A system leader works with other leaders in the ecosystem to create mutually beneficial change across multiple interacting and intersecting organizations. They take the path toward developing effective solutions shaped by multiple perspectives and entities. They cross organizational borders and stretch beyond their usual sphere of responsibilities and authority. And they do this not through control but with influence. Through a willingness to meet disruption with true collaboration, employing questions, listening, and creative thinking as influential tools that generate more effective solutions together than any single part of the system could do alone.

The three defined capabilities of a system leader are:

  1. Seeing the larger system
  2. Fostering generative conversations, and
  3. Co-creating the future.

How Does This Apply to Healthcare?

Ultimately, it is through these three capabilities that you can not only reconsider how they design, develop, and deliver their own organization’s care and services, but also how you can play a role in enhancing overall performance and achieving outsized outcomes through alliances, collaborations, and multiple provider types. Perhaps, the best way to see what this looks like in practice is through an example of how one organization used system leadership principles to engage its entire ecosystem in achieving the potential of better care for its community.

The Challenge

A small health plan managing Medicaid members, as well as members dually covered under Medicaid and Medicare, was facing shrinking skilled nursing facility (SNF) and long-term care (LTC) beds for its aged and disabled population. Moreover, it was about to enter into the CMS financial alignment initiative for its dually covered population so that it could better manage the population and rationalize the benefits under Medicaid and Medicare. The challenges were clear: address the growing shortage of SNF and LTC beds, as they may hold up hospital discharges, and find a way to reduce costs given the goals of the financial alignment initiative.

Seeing the Larger System

The health plan’s leadership stepped back to look at the larger system and to examine not just the SNF and LTC facilities, but also the continuum of care, the various community supports available, and the opportunities within the financial alignment initiative. Instead of acting immediately, the plan researched the issue and uncovered the following: 1) SNF and LTC facilities reported about 10% to 30% of their residents could step down into community; 2) those residents, however, experienced barriers such as needing personal care support, home modifications, and housing; 3) the financial alignment initiative offered certain methods of spending previously unavailable to the health plan; and 4) a series of state waivers and government services could be available to the health plan’s members. The system was greater than the health plan, encompassing primary care, community agencies, local government agencies, state waivers, and housing services, in addition to the hospital, SNF, and LTC facilities. Each area needed to become a stakeholder in this effort.

Generative Conversation

With this initial vision of moving members from SNF and LTC facilities to the community in mind, the health plan understood it could not perform all of the necessary tasks to intervene in this larger system and issued a request for proposal. After review of the proposals, the health plan selected a partnership between two organizations: a case management and social services organization and a housing services organization. While contracting and workflows were developed, stakeholders from community agencies, primary care, SNF/LTC facilities, behavioral health, personal care services, and other government agencies were convened to discuss the vision. These focused discussions served to crystallize the vision of helping members return to independent community living. The conversation continued and was structured within a key component of the effort: the core group. This group consisted of relevant stakeholders who could influence the service package of a particular member needing supports to transition into the community. Members included representatives from personal care services, behavioral health, primary care, case management, housing, and SNF/LTC facilities. The group not only reviewed cases to determine necessary intervention, but also engaged in discussions that challenged each part of the ecosystem to think and work differently.

Co-creating the Future

As the effort began, health plan leadership expected bumps and barriers. The health plan leadership worked to foster and create conditions in which change was the only viable option. One example was the speed at which a member being transitioned from LTC back to their home could receive personal care services and a primary care appointment. The organization responsible for personal care services generally had a 1-3 month turnaround time, while the member’s primary care provider expressed reservation about receiving a “complex” patient with little information. Leadership invited conversations focused on solutions that resulted in commitments. The personal care services agency worked to reduce its turnaround time to 1-2 weeks while SNF and LTC facilities, as well as case management, worked to provide adequate medical summaries to the primary care provider. An example of breaking down barriers involved changing practices. The behavioral health system posited that they could not see members prior to being discharged from SNF or LTC facilities because “that has always been the case.”

Moreover, the medication regimen of the members in SNF and LTC settings were geared towards a structured setting, not an outpatient setting (i.e., sliding scale insulin). The stakeholder group challenged the behavioral health mindset, which lead to a more proactive behavioral health service connection for members with identified conditions prior to discharge. At the same time, interventions with SNF and LTC medical directors from the health plan’s medical leadership resulted in rational medication changes which helped prepare members for discharge to the community. Lastly, the effort also led to the health plan partnering with the local housing agency and housing developers in order to generate housing opportunities for its members and secure low income housing within new housing developments.

The Results

The health plan has transitioned over 100 members to the community, resulting in people reintegrating into the social fabric, improved health, and reduced costs that include healthcare and social services. Its initial vision of addressing the shrinking number of SNF and LTC beds grew into its overall mission to keep its members healthy in the community. Moreover, its leaders participate in a greater system with a holistic view of its members. The health plan envisions an even greater system, having uncovered further issues to address such as socialization and homelessness. Its efforts are grounded in continuous learning and shaping the conditions to favor ongoing change.

The Bottom Line

The megatrends reshaping our world force us to look at our healthcare sector as an ecosystem. Working in this broader context demands a depth of knowledge across the full health and social care continuum as well as careful attention to the why and how change happens within an organization, as well as across a network of organizations. System leadership empowers health and social leaders to achieve more amidst disruptive change by seeing the larger system, fostering generative conversations, and co-creating the future. Most importantly, system leadership holds the key to unlocking the potential of better healthcare for everyone involved.