Integrating care across provider types is essential for improving outcomes for populations with complex health and social needs, particularly in primary care where coordination is critical. Primary care providers often act as the entry point into the healthcare system and are tasked with connecting patients to specialized medical, behavioral health, and social services. However, fragmented care remains a challenge due to siloed systems, lack of shared data, and inconsistent workflows. Integrated care models, such as accountable care organizations (ACOs), play a pivotal role in addressing these challenges by fostering high-quality, coordinated care. Michaela Kerrissey, Associate Professor at Harvard T.H. Chan School of Public Health, highlights that care integration requires not just clinical adjustments but also structural, procedural, and social changes that allow for seamless communication and collaboration across entities. Her research on Massachusetts’ Medicaid ACOs demonstrates that while clinical integration is more manageable within individual organizations, integrating behavioral and social services presents greater challenges due to the need for cross-organizational coordination.
Medicaid ACOs can facilitate better care integration by aligning payment structures with the goal of providing coordinated care and by supporting practice transformation at the organizational level. Kerrissey emphasizes that successful care integration not only improves care quality but also advances health equity. However, achieving these outcomes requires policymakers to provide tailored implementation supports that acknowledge the varying levels of readiness across primary care practices. Payment reforms that move away from fee-for-service models can create the financial incentives needed for providers to invest in care integration. Furthermore, fostering cross-practice learning communities and evaluating intermediate measures of integration can help identify gaps and accelerate the adoption of best practices. Ultimately, while functional and process factors are important, Kerrissey underscores that the social aspects of care integration—such as teamwork, shared norms, and leadership commitment—are equally critical to achieving sustainable change in care delivery.
